Evaluation of maternal perception of sound-provoked fetal movement as a test of antenatal fetal health.

Maternal perception of sound-provoked fetal movement was correlated with the results of nonstress cardiotocography in 1097 women with obstetric or medical antenatal risk factors. Ninety-two percent of the mothers felt fetal movements with the stimulus; all but three had a reactive non-stress test (NST). These three women were taking multiple antihypertensive drugs and were less than 33 weeks' gestation. Of 88 patients with no maternal perception of sound-provoked fetal movement, ten had nonreactive NSTs. Ultrasound confirmed the absence of fetal movement to the stimulus. The outcome in nine of these ten cases suggested some evidence of fetal compromise. Maternal perception of sound-provoked fetal movement correlated well with the results of the NST; the sensitivity (76.9%), specificity (92.8%), and negative predictive value (99.7%) were all high, although the positive predictive value was only 11.4%. Maternal perception of sound-provoked fetal movement may suffice as an inexpensive and simple method of evaluating antenatal fetal well-being in risk situations. When the mother is doubtful or does not feel the sound-provoked fetal movement, NST is indicated to evaluate the fetal health.

Does prostaglandin confer significant advantage over oxytocin infusion for nulliparas with pre-labor rupture of membranes at term?

Ninety-four nulliparous women with a poor cervical score (less than 6) who had premature rupture of membranes at term were randomized by sealed envelope into two groups. One group received immediate stimulation of labor with oxytocin infusion. The second group received two prostaglandin E2 (PGE2) 3-mg pessaries 4 hours apart, followed by oxytocin infusion, if necessary. The interval between initiation of therapy to onset of labor was significantly longer in the PG group, but the length of labor was similar in both groups. The maximum dose of oxytocin needed was significantly higher in the oxytocin group. The cesarean delivery rate in the oxytocin group was 14.9%, compared with 19.1% in the PG group (not significantly different). All seven cesareans in the oxytocin group and seven of nine in the PG group were for failed stimulation of labor. Neonatal Apgar scores at 1 and 5 minutes and admission to the neonatal intensive care unit were similar in the two groups. The incidence of maternal and neonatal infection was small and was not different in the two groups. The use of PGE2 3-mg pessaries 4 hours apart, followed by oxytocin infusion if necessary, did not confer any benefit over the use of intravenous oxytocin in obstetric or neonatal outcome when both agents were started a few hours after admission.

Direct fetal therapy for hydrops secondary to congenital atrioventricular heart block.

BACKGROUND: The outcome for the fetus with hydrops fetalis secondary to complete congenital heart block is almost uniformly poor. Transplacental fetal therapy with inotropic drugs may be unreliable in the hydropic fetus. We describe our experience of direct fetal therapy with digoxin and furosemide in three cases. CASES: In the first two cases, fetal hydrops secondary to congenital heart block was detected at 33 and 31 weeks. Direct fetal therapy with digoxin and furosemide was given and the mothers received digoxin concurrently. The neonates were born normally at 35 weeks and 33 weeks; one required ventricular pacing, but both are currently alive and well. In the third case, fetal hydrops was detected at 24 weeks, when furosemide was used alone for direct fetal therapy. The mother developed chorioamnionitis at 29 weeks and was delivered by cesarean; the infant died of cardiac failure after 48 hours. CONCLUSION: Initial direct fetal therapy with digoxin and furosemide followed by transplacental treatment with digoxin and direct fetal therapy with diuretics might improve the perinatal salvage of hydropic fetuses with congenital heart block. Treatment must be individualized because development of infection and preterm labor might defeat the objective.

Comparative study of a two dose schedule of PGE2 3 mg pessary and 1700 micrograms film for induction of labour in nulliparae with poor cervical score.

Efficacy of a two dose schedule of 3 mg pessary or 1700 micrograms film of PGE2 for induction of labour was compared in nulliparae with poor cervical score. Patient characteristics in the two groups (43 in 3 mg and 40 in 1700 micrograms group) were comparable in age, period of gestation, indications for induction of labour and in their initial cervical score. The number of patients who started labour with a two dose schedule 4 hours apart were similar in each group. The improvement of cervical score, length of labour, mode of delivery and the neonatal outcome were not different in the two groups. There was no advantage of using a film preparation over that in the form of a pessary and the use of 3 mg dose did not give significantly better results compared with the 1700 micrograms dose, in terms of obstetric or neonatal outcome.

Improved pregnancy rate after transfer of embryos grown in human fallopian tubal cell coculture.

OBJECTIVE: To evaluate the embryonic behavior in vitro and the pregnancy and implantation rates of embryos grown in a human ampullary cell coculture system. DESIGN: In a prospective study, two pronuclei embryos were cultured on human ampullary feeder layers up to the two to six-cell and blastocyst stages and replaced either as tubal, uterine, or sequential transfers. SETTING: Assisted reproductive technology program in a university-based hospital. PATIENTS: Fifty women with a mean age of 35.6 years who went through a single coculture cycle. Thirty of the patients were admitted for in vitro fertilization (IVF) and 20 for tubal embryo transfer (TET). RESULTS: The overall clinical pregnancy rate (PR) for all 50 patients was 44% per cycle (IVF, 37%; TET, 55%) and the implantation rate was 31.8% (IVF, 31.0%; TET, 32.6%). Sixty-eight percent of pregnant patients were over 35 years, and 68% had two previously failed assisted reproduction cycles. Five of 9 patients who received sequential transfers became pregnant. Three of the 22 pregnancies aborted (2 after sequential transfer), and there was one ectopic. Overall, 88% of two to six-cell stage embryos were of good quality. CONCLUSIONS: The human ampullary coculture system produces better quality embryos, increased numbers of blastocysts with improved PRs and implantation rates. The beneficial effects of the feeder layer may be through the release of embryotrophic factors and detoxification of the medium by the cells. Coculture is a new concept in assisted reproduction and has tremendous potential in boosting conception rates by mimicking the in vivo environment.

External cephalic version at term with tocolysis and vibroacoustic stimulation.

OBJECTIVE: This study compared the obstetric outcome in women who had external cephalic version (ECV) for breech presentation after 36 weeks gestation with those who did not, to see whether ECV reduces breech deliveries and cesarean section rates with reduced complications. METHOD: External cephalic version was attempted in 200 women (study group) with the use of tocolysis and vibroacoustic stimulation. The control group (ECV not attempted) comprised of 278 women with breech presentation after 36 weeks. RESULT: The cesarean section rate was 14.0% in the successful version group compared with 55.2% in the unsuccessful version group. The overall cesarean section rate in the study group was 32.5%. In the control group of 278, the fetus remained in the breech presentation in labor in 269 women with a cesarean section rate of 51.4% which was not different from the unsuccessful version group (55.2%). CONCLUSION: This study supports the randomized trials conducted earlier in that ECV after 36 weeks gestation reduced the number of breech deliveries and cesarean sections (32.5% in the study group compared with 51.4% in the control group) (P > 0.00001).

Medical management of cervical pregnancy--a report of two cases.

Cervical ectopic pregnancy is a rare life-threatening condition that can be managed conservatively. In this report, the authors describe the use of systemic methotrexate and prostaglandin (sulprostone) in the management of two cases of viable cervical pregnancy. Both cases were successfully treated without the need for surgical intervention.

Maternal serum markers for Down's syndrome pregnancies.

Down's syndrome is the most common chromosomal abnormality whose incidence increases with advancing maternal age. However, approximately 70% of all Down's syndrome foetuses occur in mothers aged less than 35. Maternal serum markers have been used in an attempt to identify Down's syndrome pregnancies in these low risk mothers. Numerous second trimester maternal serum markers have been documented in the literature and these are reviewed. The Triple test which uses second trimester maternal serum levels of alpha-feto protein, human chorionic gonadotrophin and unconjugated oestriol is the most popular combination in use today. Although it is associated with a 58% detection rate for Down's syndrome pregnancies at a false positive rate of 5%, the Triple test has its problems and these are discussed. The cost-effectiveness of Down's syndrome screening using the Triple test and its role in mothers aged 35 years or more are also explored. Several workers have reported on first trimester serum markers of foetal Down's syndrome but more data is needed before a first trimester serum screening programme for Down's syndrome is possible.

A phenotypically normal female with pseudodicentric X: correlation for statural genes.

A 14-year-old Chinese female presenting with primary amenorrhoea and poorly developed secondary sexual characteristics is described here. Cytogenetic analysis showed the presence of one normal X along with a dicentric X which had a duplication of the entire chromosome from the band Xp22.1 to Xqter. She was karyotyped as 46, XX, psu dic X (p22.1) (Xqter:Xp22.1::Xp22.1:Xqter), a variant of Turner syndrome. Both parents and a younger sister had normal karyotypes. FISH with X centromeric probes was a useful test for confirmation of the two centromeres and also in ruling out the presence of a monosomic or normal diploid X cell line.

Incidence of chromosomal abnormalities in 153 pregnancies with ultrasound detected fetal abnormalities.

One hundred and fifty-three patients with fetal abnormalities diagnosed on ultrasound were karyotyped between January 1992 and December 1993. There were 19 (12.4%) fetuses with chromosomal abnormalities. The risk of chromosomal aberrations in the malformed fetuses were increased in the presence of intrauterine growth retardation (15.4%), oligohydramnios (20%) and polyhydramnios (25%). Fetal karyotyping is thus essential in the management of such pregnancies.

Towards improved perinatal care--perinatal audit.

Perinatal audit is a measure of quality of care given in pregnancy and it gives an idea as to how the resources need to be allocated for better outcome. The perinatal mortality data in the National University Hospital over a 7-year period (1986-1992) were compiled and compared with that of the year 1982. The perinatal mortality rate (PNMR) of 14.6/1000 in 1982 declined to 8.9/1000 for the period 1986 to 1992 and the reduction was noticeable in all ethnic groups, particularly in the Malays. When lethal congenital malformations (LCMs) were excluded, the PNMR decreased to 5.7/1000. Such reduction is due to easy availability and acceptance of antenatal care, improvement in antenatal and intrapartum fetal surveillance and advances in neonatal care. Neonatal audit was extended beyond the first 7 days of birth which showed that the majority (65%) of deaths occurred in the first week and 15% occurred after the first month. The fear that intensive neonatal care serves to postpone death is not entirely substantiated. There was nearly a ten-fold rise in PNMR between the non-low birthweight and low birthweight groups. The important causes of perinatal mortality during the review period were LCMs (35.7%), complications of prematurity (17.9%) and asphyxia (15.3%). No cause was identifiable in 28.5%. Detailed analysis revealed that the standard of care could have been improved in a third of the cases (83/235) which could have led to further reduction of perinatal mortality rate.

Variability in the segregating generation of eggplant for earliness and yield.

In the past, very little efforts have been taken for development of inbred lines of brinjal through the exploitation of genetic variability present in the exotic hybrids. F2 generation obtained from the selfing of F1 hybrid provides all possible variations. So, selection with particular objectives in F2 generation is very much effective and selfing of those selected genotypes generation after generation helps to develop inbred lines (similar to the parental lines of the exotic hybrids). These inbreds with desired characters including high yield potential can be used as High Yielding Variety (HYV) as well as the parents for hybrid variety. To increase the genetic yield potential, the maximum utilization of the desirable characters for synthesizing of any ideal genotypes is essential. Variability in brinjal is expected to be immense as the fruits vary greatly in shape and size. The present investigation was undertaken at Department of Horticulture, Agricultural College and Research Institute, Madurai during 2011 to determine variability in segregants of eggplant (Solanum melogena L.). The crosses L5 x T4 (Palamedu Local x EP 65) and L4 x T1 (Alagarkovil Local x Annamalai) had the highest mean with high variability for individual fruit weight and fruit yield per plant. These crosses were best for using as a base population for further improvement in fruit yield and fruit weight as they had high heritability and genetic advance. Favorable low mean with high variability occurred for days to first flowering (earliness) in the crosses L5 x T2 (Palamedu Local x KKM 1) and L4 x T2 (Alagarkovil Local x KKM 1). Direct selection may be executed considering these genotypes for selection towards the development of early in flowering and high yielding brinjal variety.

Genetics of fertility restoration in hybrid rice.

The cross combination involving 14 male-sterile lines in rice, when crossed with different maintainers, showed fertility restoration in certain combinations. When F2 segregating populations were classified based on spikelet fertility, fertility restoration was shown to be governed by 3∶1, 9∶3∶3∶1, and 12∶3∶1, due to allelic differences. This indicated that the cytosterility of the same group showed monogenic fertility restoration, whereas crossing plants belonging to different cystosterile groups showed a digenic pattern of segregation.

Ambulatory blood pressure monitoring in pregnancy induced hypertension.

OBJECTIVE: To determine the role of ambulatory blood pressure monitoring in the diagnosis of pregnancy-induced hypertension in women detected as hypertensive in the clinic by the conventional method. DESIGN: An observational study of ambulatory blood pressure monitoring. SETTING: A teaching hospital in Singapore. METHODS: One hundred and twenty-eight women between 28-37 weeks of pregnancy diagnosed to have non-proteinuric pregnancy-induced hypertension in the clinic had 24 hours ambulatory blood pressure monitoring. The mean systolic and diastolic BP, systolic and diastolic 'white coat effect' and the diastolic load were the main parameters noted. RESULTS: One hundred and twenty subjects had valid recordings. Only 46 (38.3%) were found to be truly hypertensive on ABP monitoring, using a mean diastolic pressure cut off of 85 mmHg. The 'white-coat effect' was seen in both groups of women--the hypertensives as well as the normotensives, although the magnitude of the white coat effect had poor correlation with the clinic diastolic BP. A cut-off value for diastolic load of 20 per cent was found to detect all hypertensives correctly (sensitivity 100%) with a modest false positive rate of 17.5 per cent. CONCLUSIONS: 'White-coat hypertension' is common in pregnancy and ambulatory blood pressure monitoring would be helpful in identifying the true hypertensive without requiring unnecessary hospitalization.

Coagulation and fibrinolysis in viable mid-trimester pregnancies of normal, intrauterine growth retardation, chromosomal anomalies and hydrops fetalis and their eventual obstetric outcome.

A total of 71 pregnant women diagnosed by ultrasound to have viable fetus in late mid- trimester pregnancies of normal, IUGR, hydrops fetalis and chromosomal anomalies were studied for their coagulation, fibrinolytic and inhibitor levels with association on eventual obstetrics outcome. A hypercoagulable state was observed in all the pregnancies studied. However, higher hypercoagulation evidenced by significantly raised prothrombin formation and clot elasticity together with higher levels of D-dimer, uPA antigen and PAI-1 than observed in normal pregnancy suggests a hyperfibrinolytic/inhibitor state in hydrops fetalis pregnancy associated with bad obstetric outcome. In IUGR pregnancy associated with good outcome further enhanced clot elasticity was seen whilst no significant differences were observed in pregnancy with chromosomal anomalies when compared to uncomplicated normal pregnancy. Our study suggests that in hydrops fetalis pregnancy, further enhanced prothrombin formation and hyperfibrinolysis/inhibitor at late mid-trimester is associated with a poor obstetric outcome.

Plasminogen activators, plasminogen activator inhibitors and markers of intravascular coagulation in pre-eclampsia.

In pre-eclampsia (PE), reduced levels of plasma urokinase-like plasminogen activator (u-PA) and plasminogen activator inhibitor-2 (PAI-2), and increased levels of plasma tissue-type plasminogen activator (t-PA) antigen were seen. The majority of moderate and severe pre-eclamptic women (7 out of 10) ended up with pre-term delivery as compared with 2 out of 11 who went on to term. Patients with moderate and severe PE had significantly lower levels (mean +/- SD, ng/ml) of PAI-2 (58.4 +/- 34.9) and u-PA antigen (1.61 +/- 0.62) as compared to those with mild PE (95.6 +/- 39.3 and 1.61 +/- 0.62 and 2.12 +/- 0.61, respectively). Significantly raised t-PA antigen (14.6 +/- 5.7 ng/ml) was seen in moderate and severe PE as compared with mild PE (9.9 +/- 3.4 ng/ml). PAI-1 activity was significantly raised only in moderate and severe PE as compared with normal pregnancy. There were no significant differences in thrombin-antithrombin-III complexes, D-dimer and beta-thromboglobulin levels between the PE group and normal pregnancy, although these parameters were above the non-pregnant levels. Platelets in PE were within the range found in normal pregnancy. It appears that measurements of plasma u-PA and PAI-2 levels in patients with PE may have prognostic value in determining the outcome of pregnancy in this pregnancy disorder.

Fetal blood sampling and its complications related to the indications for fetal blood sampling.

A prospective study on fetal blood sampling (FBS) was conducted in the Fetomaternal Medicine Division of the Department of Obstetrics and Gynaecology at the National University Hospital, Singapore. FBS was performed on 159 occasions in 156 women between January, 1988 and December, 1991. The aim of this study was to identify the factors that were associated with an adverse outcome following the procedure. Twenty four abnormal pregnancies were terminated; of the remaining 132 desired pregnancies the overall pregnancy loss was 44 (33.3%), which included those within 2 weeks and those after 2 weeks of the procedure and neonatal deaths. Fetal loss occurring within 2 weeks of the procedure is considered a procedure-related loss which occurred in 19 (14.3%) of the 132 pregnancies. When the fetal loss occurred within 2 weeks of the procedure 89% had a major abnormality on ultrasonographic scanning. The conclusion from our study is that the risks of FBS were increased in abnormal pregnancies, most likely due to the underlying pathology.

Should assessment of amniotic fluid volume form an integral part of antenatal fetal surveillance of high risk pregnancy?

This study was conducted to evaluate the role of the Amniotic Fluid Index (AFI), used along with nonstress cardiotocography (NST) and fetal acoustic stimulation test (FAST), when required, in prediction of adverse pregnancy outcome. Over a 3-year period 565 pregnant women had antepartum fetal surveillance due to various high risk pregnancy factors and delivered within 7 days of the test. Antepartum fetal surveillance included nonstress cardiotocography together with estimation of AFI. Need for induction of labour, presence of meconium at rupture of membranes, Caesarean section for fetal distress, Apgar score at 5 minutes, need for neonatal endotracheal intubation, admission to neonatal special care unit and perinatal death were the main outcome measures. Nonreactive nonstress tests and Caesarean sections for fetal distress were more common and neonatal outcome was significantly poorer in patients with AFI < 5 cm than in those with higher AFI values. Of the 4 perinatal deaths in the group with AFI < 5 cm, 3 had a reactive NST within 7 days of fetal death. It is concluded that pregnancy outcome is often poor in the presence of very low AFI and in these cases a reactive NST loses its usual reassuring value. It is suggested that AFI estimation should be included as an integral part of antepartum fetal surveillance of high risk pregnancies.