Obstetrics and gynecology in the USSR.

Knowledge of Soviet obstetrics and gynecology has been mostly inaccessible to Western physicians. We share our experience regarding medical education and practice in the USSR. Medical education lasts 6 years and is followed by 2 years of postdoctorate training. Residency is limited to clinical obstetrics and gynecology. No formal subspecialty training exists. Research projects are funded and guided by the Health Ministry and Academy of Medical Science. Most articles are published in Russian and are therefore unknown to physicians in the West. Modern medical technology is not available in the practice of obstetrics and gynecology. Abortion remains the leading method of contraception. Perinatal and infant mortality in the USSR is higher than that in comparable Western countries.

The effect of fetal acoustic stimulation on fetal swallowing and amniotic fluid index.

OBJECTIVE: To determine the effect of fetal acoustic stimulation on fetal swallowing and amniotic fluid (AF) index in an attempt to understand the potential mechanism for fetal compromise following fetal acoustic stimulation. METHODS: Fetal swallowing movements and AF index were assessed in 90 full-term fetuses before and after fetal acoustic stimulation. Fetal swallowing movements were identified on a video monitor and measured in terms of the percentage of time they occurred during 30 minutes of observation. The fetal heart rate was recorded 30 minutes before and 30 minutes after fetal acoustic stimulation. RESULTS: The mean (+/- standard deviation) percentage of time spent by the fetus in swallowing increased from 16.1 +/- 6% before to 44.3 +/- 10.3% after stimulation (P < .005). The AF index decreased from 14.6 +/- 8.4 cm before acoustic stimulation to 12.8 +/- 6.8 cm afterward (not statistically significant). Seven of 17 patients (41%) with borderline AF indexes developed oligohydramnios after the fetal acoustic stimulation; two of these demonstrated persistent variable decelerations that required obstetric intervention. CONCLUSIONS: Fetal acoustic stimulation is associated with increased fetal swallowing activity, which can lead to diminution of AF volume. The AF index should be assessed in fetuses before acoustic stimulation and if the volume is low, acoustic stimulation should be used with extreme caution.

The application of color Doppler technology to the study of fetal swallowing.

OBJECTIVE: To investigate the mechanics of fetal swallowing using color Doppler technology. METHODS: The fetal face and a profile were imaged sagitally in ten fetuses at 36-41 weeks' gestation. Color-flow Doppler signals were superimposed on each gray-scale image to assess the direction and location of amniotic fluid (AF) flow with respect to anatomic structures of the fetal upper gastrointestinal and respiratory tracts during the act of swallowing. Further analysis of fetal swallowing movements was performed by a review of the ultrasonography videotapes at a slow speed. RESULTS: An initial stage of fetal swallowing was characterized by two to six sucking movements and the introduction of an AF bolus into the oral cavity. The soft palate superiorly and the tongue posteriorly and inferiorly obstructed the further flow of AF. The final stage of swallowing was characterized by low-frequency tongue movements, upward laryngeal and epiglottic movements, and narrowing of the lumen of the pharynx, directing the fluid bolus caudally. However, some AF was directed into the nasopharynx as well as the trachea. CONCLUSION: The swallowing pattern in the term fetus differs from that in the infant and adult, in that the oral and pharyngeal phases appear to be less completely developed.

Fetal cloacal anomalies: prenatal sonographic findings and differential diagnosis.

Serial sonographic findings are presented in three cases of cloacal anomalies. The following sonographic signs were noted: transient fetal ascites, bicystic intra-abdominal structure arising from the fetal pelvis, and oligohydramnios and impaired interval growth. This sequence of sonographic findings may help clarify the natural history of the developing cloacal anomaly: In the early state of its formation, urine enters the abdominal cavity via the fallopian tubes, causing ascites; later, chronic urinary and meconium irritation of tubal mucosa may cause tubal obstruction, which in turn may lead to the formation of genitourinary tract distention, hydronephrosis, and oligohydramnios. Timely diagnosis of cloacal anomalies improves the outcome of pregnancies (delivery in the tertiary care center, early operative correction).

Elevated maternal serum alpha-fetoprotein and mild fetal uropathy.

Sixty-one consecutive patients referred because of elevated maternal serum alpha-fetoprotein (MSAFP) levels and 80 referred for second-trimester ultrasound for other reasons were examined. Ultrasound examination of the genitourinary tract and assignment of phenotypic sex was done by ultrasonographers blinded to the MSAFP results. Among male fetuses with elevated MSAFP, 33% had pyelectasis compared with only 5% of controls. Among female fetuses, pyelectasis was seen in 16% of cases and no controls. Increased MSAFP not caused by an open neural tube defect may be seen in conjunction with mild benign uropathy in the second trimester.

Nonpharmaceutical ripening of the unfavorable cervix and induction of labor by a novel double balloon device.

Artificial ripening of the unfavorable cervix was attempted in 48 women using intracervical prostaglandin (PG) E2 gel applied by a cannula and in 70 others by a newly designed double balloon device (Atad Ripener Device). In the first group (phase A), application of PGE2 gel by intracervical cannula resulted in a mean increase of 3 points in the Bishop score and a mean instillation-to-delivery time of 34.2 hours. The study of labor induction by the double balloon device was carried out in two parts. One (phase B) consisted of a double-blind randomized controlled study in which, through the double balloon device, ten women received PGE2 gel and another ten were given placebo gel. There was no significant difference in the increase of Bishop score between the two groups (5.8 points in the treatment group and 6.0 in the placebo-controlled group). Ninety percent of women in both groups delivered vaginally with a mean of 20.8 hours after device insertion. The third phase of the study consisted of an open trial of inserting the double balloon device alone without PGE2, and inflating the balloons in 50 patients. A mean increase of 4.4 points in the Bishop score was noted in these women. These findings suggest that the use of the double balloon device for ripening of the unfavorable cervix is an effective and well-tolerated method of labor induction.

Diurnal non-stress test variations in healthy term fetuses. A call for evening appointments for fetal testing.

OBJECTIVE: The null hypothesis is that the time of day during which non-stress testing is performed does not influence the reactivity of the test. STUDY DESIGN: Fetal heart rate (FHR) monitoring was performed in 65 healthy term fetuses at 09:00, 14:00 and 21:00 h, in a quiet room exposed to daylight 2 h after maternal meals. Each session lasted 20 min. Smoking mothers were excluded. Statistical analysis was performed using a double-tailed t-test. RESULTS: Diurnal non-stress test (NST) variations exist and are manifested by a higher incidence of a reactive NST at 21:00 h compared to a 09:00 h assessment, and an increased number and longer duration of accelerations during a 20-min observation period at 21:00 h compared to a 09:00 h assessment. CONCLUSIONS: Evening appointments for fetal assessments may eliminate the need for additional tests due to the decreased incidence of nonreactive NSTs. These in turn will decrease both maternal anxiety and the expense of further testing.

Electronic fetal heart rate monitoring during cesarean section in cases of fetal distress.

Twelve fetuses in whom the diagnosis of fetal distress was made during first stage of labor were included in the study. All 12 patients underwent urgent cesarean section during which fetal heart rate (FHR) was recorded continuously. In 50% of the cases, marked improvement of FHR was registered early in the course of the operation. Improvement in fetal status is attributed to adequate oxygenation and cessation of uterine activity.

Endoscopic assessment of the integrity of the postcesarean uterine wall before a trial of labor. Transcervical Endoscopy Registry.

Endoscopic examination of the uterine scar site was performed on 52 women prior to a trial of labor after a previous cesarean section. A sterilized intraoperative fiberscope was introduced into the amniotic cavity after rupture of the fetal membranes under constant visual guidance. In 45 cases the site of the previous incision appeared unremarkable, and a scar from the previous surgery could not be identified. "Compromised" scars were detected in three patients, and scars were identified as vertical in four patients with no record of the type of uterine incision used for the previous surgery. Endoscopic data were confirmed postpartum in all cases. This approach seems beneficial in selected cases.

Fetal heart rate cyclicity during preterm labor.

The cyclic variation in fetal heart rate (FHR) patterns in preterm fetuses throughout labor was studied with a retrospective analysis of 49 FHR tracings. All fetuses were born preterm in good condition, and 92% exhibited the ability to change FHR cycles. A cycle was defined as an FHR pattern with consistent long-term variability in terms of amplitude range. The FHR cycles were significantly shorter in the second stage of labor as compared to the latent and active phases. Cycles of markedly diminished variability (less than or equal to 2.5 beats per minute) were observed in 16% of the fetuses during the latent phase and had a mean duration of 42 minutes, in 21% of the fetuses during the active phase with a mean duration of 68.3 minutes and in 8% of the fetuses during the second stage with a mean duration of 28.5 minutes. Knowledge of the normal length and frequency of FHR cycles is imperative for the correct interpretation of intrapartum FHR patterns in preterm fetuses.

First-trimester diagnosis of duodenal atresia.

The earliest diagnosis of duodenal atresia, at 14 weeks of pregnancy, is reported. An attempt to diagnose this entity should be considered in the first trimester, which will allow ample time for counseling, genetic testing, and decision making.

Intrapartum fetoscopy: technique and indications.

The present article summarizes six years of experience with intrapartum visualization of the uterus and its contents (fetus, umbilical cord, placenta and amniotic fluid). The choledochofiberscope, previously sterilized in 96% alcohol was introduced into the amniotic cavity via the cervical canal after spontaneous or artificial rupture of the membranes. The following abnormalities were diagnosed with high accuracy: umbilical cord complications (28 cases), placental pathology (36 cases), dehiscence of the uterine scar (2 cases), fetal dysmaturity (19 cases), congenital anomalies (15 cases). No fetal or maternal complications of fetoscopy were noted. Intrapartum fetoscopy can provide the obstetrician with important information in selected cases. Potential uses of intrapartum fetoscopy are discussed.

Fetal responses to inadvertent contact with the needle during amniocentesis.

Fetal responses in 7 cases of mid-trimester amniocentesis, complicated by inadvertent contact between the amniocentesis needle and fetal parts, were analyzed by retrospective videotape review. The incidence of inadvertent needle contact with the fetus was 0.4% (7 of 1,458). Responses included brisk withdrawal of the 'involved' small part in all cases, with the exception of a fetus with lumbosacral meningomyelocele, which failed to withdraw the foot upon direct contact with the needle. Neurologic examination was normal in all neonates except for one with meningomyelocele whose defect was at the L3-L5 level. This patient exhibited paralysis of intrinsic foot muscles and hip extensors. Surgical closure of the defect was performed 12 h after birth. At 2 years of age, no significant improvement in this patient's neurologic condition was noted. Further research is needed to assess the validity of the response to needle contact as a predictor of neonatal neurologic compromise.

Size disparity of the choroid plexuses of the lateral ventricles: prenatal diagnosis and neonatal outcome.

Fetal choroid plexuses have attracted the attention of perinatologists and geneticists because of the reported association between intrachoroid cysts and chromosomal abnormalities. This report deals with another variation in choroid plexus sonographic appearance-size variation. Sonographic follow-up results as well as neonatal outcome were analysed in five fetuses with these findings. All fetuses had a normal karyotype. Disparate choroid plexuses were not associated with other structural anomalies. None of the fetuses developed ventriculomegaly.

Fetal hydrocele: a persistent finding?

A transient type of fetal hydrocele is described. This type of hydrocele resolves in utero spontaneously and may be a variant of normal testicular development.

Magnesium sulfate and intrapartum fetal behavior.

The effect of magnesium sulfate (MgSO4) in intrapartum fetal behavior as judged by heart rate cyclicity was investigated by comparing the fetal heart characteristics of 15 term fetuses whose mothers received MgSO4 with a control group of 54 healthy term fetuses whose mothers received no antepartum medications. The duration of different fetal heart cycles and percentage of time spent in a particular cycle except for cycle C (6 to 10 beats per minute) were not different between groups. Seventy-seven percent of fetuses of the study group versus 24% of fetuses in the control group exhibited markedly diminished variability (cycle A) and 8% versus 63%, respectively, experienced cycles of increased variability (cycle D). Our observations may explain the conflicting conclusions of previous reports regarding the affect of MgSO4 on fetal heart rate variability.

Erb's palsy and fetal bruising after external cephalic version: case report.

An unusual fetal complication, Erb's palsy and fetal bruising, after successful external cephalic version is reported. Importance of fetal weight estimation prior to the attempts to perform a version is stressed.