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Biomedical subjects

J A Copel

Publications and source records attributed to J A Copel.

At least 91 records · Page 5Linked to original sources
PubMed1993

Fetal platelet counts correlate with the severity of the anemia in red-cell alloimmunization.

OBJECTIVE: To determine whether fetal anemia secondary to maternal red-cell alloimmunization is associated with thrombocytopenia. METHODS: The records of 78 patients undergoing intrauterine transfusion for red-cell alloimmunization were reviewed. Pre-transfusion fetal platelet counts were compared between hydropic and nonhydropic fetuses. A regression analysis was performed between the fetal platelet counts and the fetal bilirubin levels, hematocrits, and reticulocyte counts taken at the initial transfusion. The hematocrits, reticulocyte counts, and bilirubin levels were adjusted for gestational age by calculating the number of standard deviations (SDs) from the mean for that age or the multiples of the mean (MOM). Student t test, Pearson coefficient, and contingency table randomization test were used to analyze the data. P < .05 was considered significant. RESULTS: Thirty-seven fetuses were hydropic and 41 were nonhydropic. Hydropic fetuses had a significantly lower platelet count than nonhydropic fetuses (197.5 +/- 86.4 versus 252.6 +/- 73.7 x 10(3)/microL; P < .01). Platelet counts correlated negatively with the reticulocyte count MOM (r = -0.652; P < .01) and the hematocrit SDs below the mean (r = -0.659; P < .01), but did not correlate with the bilirubin MOM (r = -0.183; P = .2). CONCLUSION: Hydropic and severely anemic fetuses are at increased risk for thrombocytopenia. We suggest that increased erythropoiesis diverts the hematopoietic stem cell away from thrombopoiesis.

Anemia, Hemolytic↗
PubMed1993

Fetal echocardiography and fetal cardiology: indications, diagnosis and management.

Over the last 15 years, the ultrasound examination of the fetal heart has become increasingly sophisticated. Fetal echocardiography is now paramount in making an early and accurate assessment of cardiovascular structure as well as diagnosing and treating fetal arrhythmias. For the fetal sonographer, the increasing challenge of fetal evaluation has been paralleled by advancing technology. Today, a complete fetal echocardiographic study includes the structural and rhythm analysis using a combination of two-dimensional imaging, M-mode scanning, pulsed- and continuous-wave Doppler measurements, and color-flow mapping. When the data obtained from the fetal echocardiogram suggest normal cardiac structure, the reassurance provided to the family at risk is immeasurable. When a prenatal diagnosis of structural or rhythm abnormalities is obtained, the health care team can outline a management strategy to optimize the care and support given to the fetus, mother, and family.

Arrhythmias, Cardiac↗
PubMed1993

Erythropoietin in human fetuses with immune hemolytic anemia and hydrops fetalis.

OBJECTIVE: To determine whether plasma erythropoietin is increased in fetuses with anemia due to Rh isoimmunization. METHODS: Hemoglobin and erythropoietin were measured in samples obtained by funipuncture from 15 fetuses with Rh isoimmunization (gestational age 26.2 +/- 5.0 weeks, mean +/- standard deviation) and from 13 control fetuses (23.1 +/- 6.7 weeks). Hemoglobin and erythropoietin also were determined in umbilical cord blood collected at birth from 20 term fetuses delivered by elective cesarean. RESULTS: Fetuses with Rh isoimmunization had lower hemoglobin and higher plasma erythropoietin measurements than mid-gestation controls (6.1 +/- 3.9 versus 10.7 +/- 1.5 g/dL and 105.5 +/- 168.1 versus 12.5 +/- 3.1 mU/mL, P < .05, respectively). Hemoglobin and plasma erythropoietin increased with gestational age in control fetuses. There was an inverse association between hemoglobin and plasma erythropoietin in control and Rh-isoimmunized fetuses (r = -0.56, P < .005). Using multiple linear regression, hemoglobin and gestational age were associated independently with plasma erythropoietin (overall F2,25 = 12.3, multiple r2 = 0.49, P < .001). Despite marked decreases in hemoglobin, fetuses below 24 weeks' gestation had minimal increases in plasma erythropoietin compared to fetuses above that gestational age. Mildly anemic Rh-isoimmunized fetuses (hemoglobin 11.6 +/- 2.0 g/dL) delivered vaginally had significantly higher erythropoietin levels in umbilical cord plasma than Rh-isoimmunized fetuses with comparable hemoglobin (10.9 +/- 3.5 g/dL) delivered by elective cesarean without labor (1246 +/- 856 versus 106 +/- 66 mU/mL, respectively, P < .05). CONCLUSION: Fetuses with anemia at mid to late gestation respond with increases in plasma erythropoietin, but these changes are substantially attenuated before 24 weeks' gestation.

Anemia, Hemolytic, Autoimmune↗
PubMed1993

Ultrasound screening for fetal structural anomalies.

Ultrasound prenatal diagnosis of structural anomalies has become almost a separate branch of obstetrics. The advantages of performing ultrasound in pregnancies at high risk for fetal structural anomalies are clear. Patients and the news media have placed ever-increasing expectations on persons performing diagnostic ultrasound of the fetus. However, the benefits and cost-effectiveness of routine ultrasound screening during pregnancy remain unclear. This review focuses on three controversial topics related to the use of screening ultrasound for fetal structural anomalies: routine ultrasound screening, the four-chamber view, and amniocentesis versus ultrasound for detection of neural tube defects.

Amniocentesis↗
PubMed1992

Outcome of prenatally detected cardiac malformations.

Reliable, prenatal detection of congenital heart disease has become possible over the past decade with the evolution of fetal echocardiography. We have documented the outcome of 170 cardiac defects diagnosed prenatally since 1984. Of 170 cases, 55 (32%) had major extracardiac malformations and 45 (28%) chromosomal abnormalities (16 had both). Elective termination was chosen in 77 (45%) pregnancies. Of 93 continuing pregnancies 15 were stillborn and 43 died postnatally (48% of these fetuses and infants had extracardiac or chromosomal anomalies, or both). Thirty-five patients survive at 1 to 80 months (mean 36). Aneuploidy or extracardiac defects are present in 20% of survivors. Nonimmune hydrops secondary to cardiac failure was present in 7 continuing pregnancies and none of these patients survived. The prognosis of prenatally diagnosed cardiac lesions is negatively influenced by the presence of cardiac failure, aneuploidy or extracardiac malformations, or a combination of these. Optimal counseling and management requires the identification of these conditions when present.

Abortion, Eugenic↗
PubMed1992

Fetuses with Down syndrome have disproportionately shortened frontal lobe dimensions on ultrasonographic examination.

OBJECTIVE: The purpose of our study was to determine whether the frontal lobe is significantly smaller than normal in the Down syndrome fetus in midtrimester. STUDY DESIGN: Frontothalamic distance, measured from the inner table of the frontal bone to the posterior thalamus, and frontothalamic distance/biparietal diameter ratio were compared in 125 normal and 19 Down syndrome fetuses between 16 and 21 weeks' gestation. RESULTS: In the Down syndrome group 52% had frontothalamic distance < 10th percentile. When the frontothalamic distance and the frontothalamic distance/biparietal diameter ratio were expressed as multiples of the normal median to eliminate variation caused by gestational age, the mean value of multiples of the median in Down syndrome fetuses was compared with the mean value of multiples of the median in normal fetuses and was found to be significantly smaller (p < 0.0019 and p < 0.0177, respectively). When an observed-to-expected frontothalamic distance ratio of < or = 0.84 is used as a cutoff to screen for Down syndrome, sensitivity, specificity, and positive predictive values of 21.2%, 95.2%, and 1.2%, respectively, are achieved in a population with a 1:270 risk. CONCLUSION: Frontal lobe dimension is significantly shortened in Down syndrome fetuses.

Down Syndrome↗
PubMed1992

Fetal cardiovascular physiology and therapy.

The ability to diagnose fetal cardiovascular malformations prenatally has been established during the past 14 years. This has naturally led to an increased interest in the possibility of providing timely therapy in the neonatal period and has raised the prospects for prenatal intervention. Before medical, catheter, and/or surgical interventions are performed, however, it is important to understand the normal and abnormal physiology of the fetal cardiovascular system. Significant insights have been gained into human fetal cardiovascular physiology utilizing data previously gleaned from fetal lamb models and correlating anatomic, pulsed Doppler, and color flow Doppler observations that have been made echocardiographically during the second and third trimesters of human fetal cardiac development. Regional blood flow distribution studies in the human have demonstrated a relative right-ventricular volume dominance in the human fetus of a somewhat lesser magnitude than previously described in the lamb. Observations of ventricular filling characteristics suggest a relative paucity of diastolic 'reserve' in the human fetal heart implying a relative sensitivity to acute volume overloading. The human fetal heart, like that of the fetal lamb, also appears to have a relatively modest amount of 'systolic reserve', making the heart particularly susceptible to acute ventricular afterload. Further studies have demonstrated the ability to recognize altered intrauterine shunt flow across the fetal ductus arteriosus and foramen ovale. As predicted in fetal lamb models, alterations in shunt flow accompany major malformation complexes including ventricular hypoplasia. Studies to date suggest that attempts at surgical intervention should be made very cautiously due to the inability to ascertain whether altered shunt flow patterns precede (cause?) or follow the development of structural abnormalities.

Animals↗
PubMed1991

Foramen ovale size in the normal and abnormal human fetal heart: an indicator of transatrial flow physiology.

We used fetal echocardiography to measure the sizes of the foramen ovale and atrial septum in 80 human fetuses from 17.5 to 38 weeks gestation. Forty-six fetuses had normal cardiac anatomy, 19 had left heart obstructive lesions, and 15 had right heart obstructive lesions. Pulsed and color flow Doppler studies were incorporated when available. We found that normal fetuses had a foramen ovale/atrial septum size ratio of 0.33 +/- 0.04 (mean +/- SD). In all (52%) fetuses in which it was available, pulsed Doppler study revealed bidirectional, but predominantly right-to-left, flow through the foramen ovale. Fetuses with left heart obstructive lesions had a foramen ovale/atrial septum size ratio smaller than normal (0.28 +/- 0.05; p < 0.001). Seven of nine fetuses with left heart obstructive lesions who had color Doppler studies demonstrated reversal of the normal flow pattern, exhibiting unidirectional left-to-right transforamenal flow. Those with right heart obstructive lesions had a larger than normal foramen ovale/atrial septum size ratio (0.47 +/- 0.04; p < 0.001). Nine fetuses with right heart obstructive lesions had color Doppler studies which demonstrated almost exclusive right-to-left transforamenal flow. We conclude that foramen ovale/atrial septum size ratio and Doppler interrogation of transatrial flow are helpful adjuncts in determining the presence of congenital heart disease in utero. In addition, early detection of abnormal foramen ovale/atrial septum size ratio may predict whether left or right ventricular development will be impaired throughout gestation, even before gross disparity of ventricular size is apparent.

Journal Article↗
PubMed1991

Fetal echocardiography in multiple gestations.

We reviewed fetal echocardiograms from 36 multiple gestations from 20 weeks gestation to term. Seven sets of twins plus one set of triplets were referred because of a suspect cardiac anomaly in one fetus; heart disease was confirmed in one fetus of six sets of twins and in one triplet. Six sets were referred because of extracardiac malformations and heart disease was confirmed in two sets (including both twins in one set). The remaining case was detected in a patient sent for evaluation of karyotypic abnormality. Thus 11 fetal cardiac defects were detected in ten pregnancies. Chromosomes were abnormal in three of the anomalous fetuses. Two sets discordant for heart disease were monochorionic. Intervention, including a change in the planned location of delivery, or maternal digitalization for fetal congestive failure, occurred in six. We conclude that fetal echocardiography is feasible and useful in appropriate multiple gestations. Although often ethically complex, the information gained can be applied to patient management.

Journal Article↗
PubMed1991

Hypoplastic left heart syndrome: prenatal diagnosis, clinical profile, and management.

We diagnosed hypoplastic left heart syndrome, generally regarded as a lethal congenital heart defect, by fetal echocardiography in 20 pregnancies in the last 5 years. The clinical profile, management, and outcome of these pregnancies were reviewed. We found a 40% association of karyotype and extracardiac malformations. Elective abortion was performed in nine pregnancies. Two of seven live-born babies had early neonatal assessment and intervention as a result of in utero diagnosis and counseling. Prolonged survival was achieved in both infants. We conclude that prenatal diagnosis of the hypoplastic left heart syndrome necessitates complete evaluation of the fetus for associated genetic and extracardiac malformations. Prenatal diagnosis of this defect provides opportunities for in depth counseling of parents and obtaining informed consent for either postnatal intervention or nonintervention before the medical and emotional complexities associated with the neonatal intensive care setting are encountered.

Chromosome Aberrations↗
PubMed1991

Tricuspid valve disease with significant tricuspid insufficiency in the fetus: diagnosis and outcome.

The echocardiographic studies and clinical course of 27 fetuses (mean gestational age 26.9 weeks) diagnosed in utero with tricuspid valve disease and significant tricuspid regurgitation were reviewed. The diagnosis of Ebstein's anomaly was made in 17 of the fetuses, 7 had tricuspid valve dysplasia with poorly developed but normally attached leaflets and 2 had an unguarded tricuspid valve orifice with little or no identifiable tricuspid tissue. One fetus was excluded from data analysis because a more complex heart lesion was documented at autopsy. All fetuses had massive right atrial dilation and most who were serially studied had progressive right-sided cardiomegaly. Hydrops fetalis was found in six cases and atrial flutter in five. Associated cardiac lesions included pulmonary stenosis in five cases and pulmonary atresia in six. Four fetuses with normal forward pulmonary artery flow at the initial examination were found at subsequent study to have retrograde pulmonary artery and ductal flow in association with the development of pulmonary stenosis (n = 1) and pulmonary atresia (n = 3). On review of the clinical course of the 23 fetuses (excluding 3 with elective abortion), 48% of the fetuses died in utero and 35% who were liveborn died despite vigorous medical and, when necessary, surgical management, many of whom had severe congestive heart failure. Of the four infants who survived the neonatal period, three had a benign neonatal course, all of whom were diagnosed with mild to moderate Ebstein's anomaly; only one had pulmonary outflow obstruction. An additional finding at autopsy was significant lung hypoplasia documented in 10 of 19 autopsy reports.(ABSTRACT TRUNCATED AT 250 WORDS)

Ebstein Anomaly↗
PubMed1991

Cardiac growth in fetuses of diabetic mothers with good metabolic control.

To evaluate cardiac growth in fetuses of those diabetic mothers with good metabolic control, we examined M-mode echocardiographic measurements obtained from 24 fetuses of diabetic mothers (FODM) and compared these with measurements from 31 normal fetuses of similar gestational age. Fetuses were grouped into three gestational periods: 20 to 26 weeks, 27 to 33 weeks, and 34 to 40 weeks. The mothers were believed to have good metabolic control on the basis of mean daily glucose profiles and glycosylated hemoglobin A (HbA1C) values of approximately 110 mg/dl (610 mumol/L) and 7.5%, respectively, before fetal scanning, and estimated fetal weight similar to that of normal fetuses during all three gestational periods. Both FODM and normal fetuses had significant increases in M-mode measurements from period 1 to period 3, but in FODM, cardiac hypertrophy developed by late gestation (period 3). This involved the interventricular septum (6.1 +/- 0.7 vs 4.9 +/- 0.3 mm, p less than 0.05), right ventricular free wall (5.7 +/- 0.8 vs 3.2 +/- 0.3 mm, p less than 0.01), and left ventricular free wall (6.4 +/- 0.6 vs 3.3 +/- 0.4 mm p less than 0.01). The interventricular septum/right ventricular free wall ratio was similar, whereas the interventricular septum/left ventricular free wall ratio in FODM was smaller by period 3 (1.0 +/- 0.1 vs 1.6 +/- 0.1, p less than 0.05). The right ventricular diastolic dimension was similar, but the left ventricular diastolic dimension was significantly smaller in FODM during periods 2 and 3 (8.2 +/- 1.2 vs 12.2 +/- 0.7 mm, p less than 0.05). Strict metabolic control did not prevent FODM from having abnormal cardiac growth. We conclude that good metabolic control results in normal estimated fetal weight but that FODM remain at risk for mild global cardiac hypertrophy and altered diastolic dimensions.

Blood Glucose↗