Early onset, severe fetal growth restriction with absent or reversed end-diastolic flow velocity waveform in the umbilical artery: perinatal and long-term outcomes.

OBJECTIVE: To assess perinatal and long-term outcomes for pregnancies complicated by early onset, severe fetal growth restriction with absent or reverse end-diastolic flow velocity waveform (AREDF) in the umbilical artery. METHODS: A retrospective cohort study of 36 singleton pregnancies with AREDF when the estimated fetal weight (EFW) is less than 501 g at presentation. RESULTS: At presentation, the median gestational age and EFW were 24 (18-29) weeks and 364 (167-496) g, respectively. The median interval between presentation and live birth or diagnosis of intrauterine fetal death (IUFD) was 13 (0-60) days. Delivery was for IUFD in 19 cases (53%), fetal indications in 13 cases (36%) and maternal indications in four cases (11%). Caesarean section (CS) was performed for the 17 live births of which 10 (59%) were by classical CS. Of the total cohort, five infants survived to hospital discharge giving an overall perinatal survival rate of 14%. All survivors had short-term morbidity. The cognitive function in four children was assessed as normal at two years of age. One survivor had developmental delay. None of the surviving children had any evidence of cerebral palsy. CONCLUSION: The overall perinatal survival rate for pregnancies complicated by early onset, severe growth restriction with an EFW of < 501 g and AREDF is low. When delivery occurs for fetal indications, the majority of these women require classical CS. Short-term neonatal morbidity is high though none of the survivors had cerebral palsy.

Specific ultrasonographic features of perinatal lethal hypophosphatasia.

Prenatal diagnosis of perinatal lethal hypophosphatasia (PL-HPH) by ultrasonography is difficult as PL-HPH must be differentiated from other skeletal dysplasias with short long bones and poor mineralization of the skeleton, such as osteogenesis imperfecta type II and achondrogenesis/hypochondrogenesis. Here we present a case of molecularly confirmed PL-HPH and illustrate specific ultrasonographic findings that help to distinguish PL-HPH from similar conditions.

Rapid aneuploidy testing (knowing less) versus traditional karyotyping (knowing more) for advanced maternal age: what would be missed, who should decide?

OBJECTIVES: The application of rapid aneuploidy testing as a stand-alone approach in prenatal diagnosis is much debated. The major criticism of this targeted approach is that it will not detect other chromosomal abnormalities that will be picked up by traditional karyotyping. This study aimed to study the nature of such chromosomal abnormalities and whether parents would choose to terminate affected pregnancies. DESIGN: Retrospective study on a cytogenetic database. SETTING: Eight public hospitals in Hong Kong. PARTICIPANTS: The karyotype results of 19 517 amniotic fluid cultures performed for advanced maternal age (>or=35 years) from 1997 to 2002 were classified according to whether they were detectable by rapid aneuploidy testing. The outcomes of pregnancies with abnormal karyotypes were reviewed from patient records. RESULTS: In all, 333 (1.7%) amniotic fluid cultures yielded abnormal karyotypes; 175 (52.6%) of these were detected by rapid aneuploidy testing, and included trisomy 21 (n=94, 28.2%), trisomy 18 or 13 (n=21, 6.3%), and sex chromosome abnormalities (n=60, 18.0%). The other 158 (47.4%) chromosomal abnormalities were not detectable by rapid aneuploidy testing, of which 63 (18.9%) were regarded to be of potential clinical significance and 95 (28.5%) of no clinical significance. Pregnancy outcomes in 327/333 (98.2%) of these patients were retrieved. In total, 143 (42.9%) of these pregnancies were terminated: 93/94 (98.9%) for trisomy 21, 20/21 (95.2%) for trisomy 18 or 13, 19/60 (31.7%) for sex chromosome abnormalities, and 11/63 (17.5%) for other chromosomal abnormalities with potential clinical significance. There were no terminations in the 95 pregnancies in which karyotyping results were regarded to be of no clinical significance. CONCLUSIONS: 'Knowing less' by the rapid aneuploidy stand-alone testing could miss about half of all chromosomal abnormalities detectable by amniocentesis performed for advanced maternal age. Findings from two fifths of the latter were of potential clinical significance, and the parents chose to terminate one out of six of the corresponding pregnancies. If both techniques are available, parents could have enhanced autonomy to choose.

Fetal growth spurt and pregestational diabetic pregnancy.

OBJECTIVE: To assess the timing of fetal growth spurt among pre-existing diabetic pregnancies (types 1 and 2) and its relationship with diabetic control. To correlate fetal growth acceleration with factors that might influence fetal growth. RESEARCH DESIGN AND METHODS: This retrospective study involved all pregestational diabetic pregnancies delivered at a tertiary obstetric hospital in Australia between 1 January 1994 and 31 December 1999. Pregnancies with major congenital fetal anomalies, multiple pregnancies, small-for-gestational-age pregnancies (<10th centile), and those that were terminated before 20 weeks were excluded. In this cohort, pregnancies delivered at term had at least four ultrasound scans performed. The first scans were performed before 14 weeks of gestation and were regarded as dating scans. Abdominal circumference measurements were retrieved from the ultrasound reports. The z-scores for abdominal circumferences, according to the gestational age, were calculated. The gestations when the ultrasound scans were performed were stratified at four weekly intervals beginning at 18 weeks and continuing through the rest of the study. Majority of these diabetic pregnancies had ultrasound scans performed at 18, 28, 32, and 36 weeks. The abdominal circumference z-scores for pregnancies with large-for-gestational-age (LGA) babies (>90th centile for gestation) were compared with babies with normal birth weights. RESULTS: A total of 101 diabetic pregnancies were included. Diabetic mothers, who had LGA babies, had significantly higher prepregnancy body weight and BMI (P < 0.05). There were no differences in maternal age or parity among the two groups. There were also no differences in the first-, second-, and third-trimester HbA(1c) levels between the two groups. The abdominal circumference z-scores were significantly higher for LGA babies from 18 weeks and thereafter. The differences increased progressively as the gestation advanced. Maximum difference was noted in the third trimester (30-38 weeks). CONCLUSIONS: Fetal growth acceleration in LGA fetuses of diabetic mothers starts in the second trimester, from as early as 18 weeks. In this study, glucose control did not appear to have a direct effect on the incidence of LGA babies, and such observation might result from the effects of other confounding factors.

Consensus statement on iodine deficiency disorders in Hong Kong.

This article reviews the available data on the study of iodine deficiency disorders in Hong Kong and to discuss the approach towards preventing such disorders in Hong Kong. The importance of iodine and iodine deficiency disorders is described, and the available data on the dietary iodine intake and urinary iodine concentration in different populations of Hong Kong are summarised and discussed. Dietary iodine insufficiency among pregnant women in Hong Kong is associated with maternal goitrogenesis and hypothyroxinaemia as well as neonatal hypothyroidism. Borderline iodine deficiency exists in the expectant mothers in Hong Kong. Women of reproductive age, and pregnant and lactating women should be made aware and educated to have an adequate iodine intake, such as iodised salt, as an interim measure. A steering group involving all stakeholders should be formed to advise on the strategy of ensuring adequate iodine intake, including universal iodisation of salt in Hong Kong. Continuous surveillance of iodine status in the Hong Kong population is necessary.

Avoiding manual removal of placenta: evaluation of intra-umbilical injection of uterotonics using the Pipingas technique for management of adherent placenta.

BACKGROUND: Manual removal of placenta is performed in 1-3% of cases, and whilst a well established and relatively safe procedure, it is not without complications, which include infection, hemorrhage, uterine rupture, and occasional maternal death. METHODS: A three-arm randomized controlled trial of 50 IU Syntocinon (in 30 ml N saline) versus 800 mcg misoprostol (in 30 ml N saline) versus 30 ml N saline alone (control), injected into the placental bed via the umbilical vein using the Pipingas method. A group sequential research model (triangular test: PEST4) was adopted to minimize the sample size, as retained placenta is a relatively uncommon condition. RESULTS: No significant difference in the rate of manual removal was observed between the control and Syntocinon groups. On triggering the automatic stopping rule for this arm of the trial all subsequent cases recruited were allocated to receive either Syntocinon or misoprostol. After a total of 54 cases a significant reduction in manual removal of placenta was observed in the misoprostol group, triggering the automatic stopping rule and terminating the trial. CONCLUSION: Misoprostol (800 mcg) dissolved in 30 ml N saline and administered by intraumbilical injection using the Pipingas technique significantly reduces the need for manual removal for retained adherent placenta, whereas Syntocinon has similar effectiveness to injection of N saline alone.

Transvaginal sonography in the detection of retained products of conception after first-trimester spontaneous abortion.

PURPOSE: The aim of this study was to assess the use of transvaginal sonography to detect retained products of conception after first-trimester spontaneous abortion. METHODS: All women who arrived at our hospital with spontaneous first-trimester abortions were included in this study and underwent transvaginal sonography. A sonographic diagnosis of "incomplete abortion" was based on a bilayer endometrial thickness of more than 8 mm. The final diagnosis of complete or incomplete abortion was based on the histopathologic findings at dilatation and curettage. The sensitivity and specificity of both clinical and sonographic examinations for detecting products of conception were assessed. RESULTS: A total of 113 women were recruited, and 14 were excluded for various reasons. Among 52 women with a clinically incomplete abortion, only 50% had retained products of conception. The use of transvaginal sonography resulted in a 29% (15/52) reduction of surgical intervention in these women. On the other hand, 30% (14/47) of women with a clinical diagnosis of complete abortion had retained products of conception. The sensitivity and specificity of cervical status for detecting retained products of conception were 65% and 56%, respectively, whereas the overall sensitivity and specificity of transvaginal sonographic examination (bilayer endometrial thickness 8 mm or less) were 100% and 80%, respectively. CONCLUSIONS: Transvaginal sonography is a useful supplement to clinical assessment in women who experience a spontaneous first-trimester abortion. If this modality is used to assess the uterine cavity, the cervical status can be ignored. Use of transvaginal sonography should reduce unnecessary general anesthesia and uterine curettage.

Nasal bone hypoplasia: is it a common finding amongst chromosomally normal fetuses of southern Chinese women?

OBJECTIVE: To assess the incidence of nasal hypoplasia among fetuses of southern Chinese women. METHODS: This prospective observational study was conducted at Princess Margaret Hospital, Hong Kong. All pregnant women referred for chromosomal studies before 14 weeks were assessed. The crown-rump length, nuchal translucency thickness, and nasal bone were assessed between 11 and 14 weeks. RESULTS: A total of 143 women were recruited. In 119 fetuses, facial profiles were successfully obtained and the presence or absence of nasal bones was assessed. One hundred and fourteen fetuses had normal karyotypes. The rate of absence nasal bone when assessed between 11-14 weeks was 0.88% in the fetuses with a normal karyotype. During the same period, 2 out of 3 fetuses with Down syndrome had absence of nasal bones. A nasal bone was visualized in one fetus with Edward syndrome and the other with Turner syndrome (45 X). CONCLUSION: The incidence of nasal hypoplasia is not increased among fetuses of southern Chinese women. Assessment of ossification of the nasal bone can be used to supplement first-trimester screening in Chinese women.

Human parvovirus B19 infection in pregnancy: should screening be offered to the low-risk population?

Human parvovirus B19 infection during pregnancy can result in fetal hydrops and death. Intra-uterine transfusion in hydropic fetuses affected by the virus can reduce perinatal deaths. Up to 33% of women with this infection are asymptomatic. In view of the significant adverse outcomes, the role of routine screening among low-risk pregnant women is discussed.