Biomedical subjects
Publications and source records attributed to A Kurjak.
Recent significant improvements in the antenatal diagnosis of fetal malformations has created many legal dilemmas. This has also stimulated reconsideration of the role of tort law as a vehicle for compensating infants for antenatal injuries. The Zagreb group has been studying this problem for the last 4 years and present their findings.
A retrospective analysis of the ultrasonic growth patterns of two 13-15 trisomies, two 18-trisomies and eight 21-trisomies is presented. The patterns were examined by serial cephalometry, abdominometry and head-to-abdomen circumference measurements. Early and symmetric growth retardation was revealed by ultrasonography and later confirmed by postnatal pediatric examinations in the 13-15 trisomies and 18-trisomies. In the 21-trisomies, fetal growth was normal.
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Fetal renal function was evaluated in 255 normal singleton pregnancies between 22 and 41 weeks of gestation and in 133 complicated pregnancies. Hourly fetal urinary production rate (HFUPR), fetal glomerular filtration rate (GFR), fetal tubular water reabsorption (TWR), and the effect of furosemide on fetal micturition was evaluated by ultrasound and a combination of ultrasound and biochemical tests. In normal pregnancies, the HFUPR increased from 2.2 ml/hr at 22 weeks of gestation to 26.3 ml/hr at 40 weeks of gestation. The fetal GFR was 2.66 ml/min at term, and the percentage of TWR was 78%. In complicated pregnancies, the HFUPR was above normal in 5.7% of the growth-retarded fetuses and below the tenth percentile in 58.6%. The GFR was below normal in 68.2% of the group of complicated pregnancies, but TWR did not significantly differ from that in the normal pregnancies. The effect of furosemide was the same in both growth-retarded and normal fetuses. In diabetic pregnancies, HFUPR values varied considerably and correlated with the fetal size. The HFUPR was normal in anencephalic fetuses and in 90.0% of the pregnancies with hydramnios.
With remarkable improvements in antenatal, intrapartum and the newborn care, the proportion of perinatal problems attributable to congenital abnormalities has significantly increased. The number of deaths due to fetal malformations in some countries now approaches the number due to prematurity and it is justifiable to believe that abnormalities will soon be heading the league of causes of perinatal death. Even with the most advanced treatment teams and resources, many seriously malformed children cannot be habilitated to any reasonable degree. It is therefore obvious that the future of these types of disorders lies ultimately in their prevention. This has long been the hope of obstetricians and in certain abnormalities this can become a reality. With the advent of ultrasound, many structural anomalies cannot be evaluated by direct visualization of the placenta and fetal anatomy. The number of pregnancies monitored available and as public education about genetics increases. Diagnostic ultrasound has proved to be a powerful means of preventing the birth of babies with significant defects. If this has not been achieved in early pregnancy, the knowledge that the fetus is or may be abnormal at the end of pregnancy can still be valuable, since the management of patients before and during labour could be radically altered. Therefore, ultrasound examination should be preferred as the initial test because it is without risk and produces no side effects.
The accuracy of 4 ultrasonic parameters and their combined use of detecting fetal growth retardation in a group of 260 small-for-dates infants are analyzed. Abdominal circumference measurement was the most accurate single ultrasonic technique. By combining this measurement with fetal cephalometry, it was possible to diagnose antenatally 96.8% of the small-for-dates infants. Fetal urinary production was below the normal mean in 94.3% of these infants. All except 1 asymmetric growth-retarded fetus had a fetal breathing movement rate lower than that of a normal fetus. The perinatal mortality was significantly decreased in a group of ultrasonically detected growth-retarded fetuses, as compared with the group of unrecognized small-for-dates fetuses.
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Over a period of four years, 41 cases of abnormal multiple pregnancies were diagnosed successfully by ultrasound. These include several rare combinations of abnormalities. The most frequent was a normal pregnancy and a synchronous blighted ovum. Others were twin blighted ova, blighted ovum and missed abortion, missed abortion in both gestational sacs, two embryonic echoes with the development of only one baby, normal fetus and an anencephalic twin, normal fetus and fetus papyraceous, and triplets with two fetuses papyraceous. The results suggest that one or more gestational sacs may be resorbed during pregnancy without any adverse effect on the coexisting normal fetus. From a practical point of view, it is important to be aware of these possibilities before giving the final diagnosis of multiple pregnancy to the patient. The more diagnostic ultrasound is used in obstetrics, the more rare abnormalities associated with multiple pregnancies will be revealed.
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Over a period of two years, 7 137 localisations of placenta were performed. In 67 patients on the first examination it was found that the lower margin of placenta reached the internal os of the uterus. All these patients were followed up by examinations every two or four weeks. In 63 of the 67 patients, placental migration was found involving a change in the level of the lower placental edge from the cervix towards the fundus. The change in this position varied from 3 to 9 cm. All four cases where the placenta extended from anterior to posterior wall ended as placenta praevia. Ultrasonic proof of placental migration shows the necessity for ultrasonic examination shortly before the birth, as only then is the final diagnosis of placenta praevia possible.
The effect of continuous epidural analgesia on the fetus, newborn, and uterine activity was studied in a group of 50 parturients. No untoward effects, either in the fetus or uterine activity, that could be ascribed to this procedure, were observed. The authors use their own modicifation of the epidural block by titrating the amount of the local anesthetic according to the intensity of pain in labour.
The fetal abdomen was measured with an ultrasonic contact scanner in order to correlate abdomenal circumference and birth weight. A sample of 134 measurements was used to calculate a standard graph, which was then tested against a subsequent 280 measurements, giving a mean estimation error of 105 Gm. Head-to-abdomen circumference ratio measurements were used to assess the type of growth retardation.
Three hundred ninety fetal crown-rump measurements by ultrasound echography were performed in order to correlate the crown-rump length with gestational age between the sixth and fourteenth weeks of gestation. A blind trial in 58 patients showed a good correlation of ultrasonically determined age and menstrual age. A graph of normal values was designed and is currently being used in routine work.