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The Robin anomalad was diagnosed by the sonographic detection of polyhydramnios and fetal micrognathia in a patient at risk because of a previously affected child. Ultrasound in the second trimester failed to demonstrate any facial anomaly, but mandibular hypoplasia was clearly documented in the third trimester. The antenatal diagnosis allowed immediate neonatal assistance to prevent glossoptosis-induced respiratory failure.
Fetal outcome was studied in eight cases of isolated bilateral fetal hydrothorax. All patients were referred because of polyhydramnios. Spontaneous resolution of pleural effusion was observed twice. No remarkable change in the degree of hydrothorax was demonstrated in the remaining six cases. All eight cases resulted in the birth of a live infant without other abnormalities. Postnatal intubation, which was carried out in all six fetuses with hydrothorax, was always followed by spontaneous respiration. Subsequent thoracocentesis resulted in the collection of 50 to 500 ml of serous fluid. Sustained intubation (7 days) was necessary in only two infants because of developing respiratory distress as a result of prematurity or recurrent pleural fluid accumulation. All eight infants were alive and well at the age of 1 month. Although in the present study noninvasive management of isolated fetal hydrothorax seems to have been justified, a larger multicenter study is needed to compare survival with and without pleuroamniotic shunting.
In a total of 301 placental biopsies in the second and third trimesters, 225 were performed because of suspicious ultrasonographic findings. In this group there was a high rate of aneuploidies (20%). As opposed to the alternative methods for rapid karyotyping, placental biopsies can easily be performed even in pregnancies with abnormal amounts of amniotic fluid. Oligohydramnios and polyhydramnios were key ultrasonographic findings in 38% of cases and were found to be associated with 22% of abnormal chromosomal findings. Suggestive ultrasonographic findings seem to justify the exclusive use of direct preparation.
Necrosis of the cerebral white matter may be identified in living infants with echoencephalography. Echoencephalographic studies were performed in 89 twins and 12 triplets at less than 36 weeks of gestation to determine the incidence and complications associated with antenatal necrosis of the cerebral white matter. Antenatal necrosis of the cerebral white matter was identified when brain atrophy or cavities in the white matter were present by day 3 of life. Fourteen infants (13.8%) were considered to have antenatal necrosis of the cerebral white matter. The incidence of antenatal necrosis of the cerebral white matter was higher in monochorionic than in dichorionic infants (30% vs 3.3%; p less than 0.001). Univariate analysis showed that antenatal necrosis of the cerebral white matter was significantly associated with polyhydramnios, intrauterine fetal death of the cotwin, hydrops, multiple placental vascular connections, and placental artery-to-artery, vein-to-vein, and artery-to-vein anastomosis. Logistic regression analysis showed that antenatal necrosis of the cerebral white matter was predicted by the presence of either artery-to-artery or vein-to-vein anastomosis and by intrauterine fetal death of a cotwin. Vein-to-vein anastomosis had the strongest association, because 89% of seven infants with vein-to-vein anastomosis demonstrated antenatal necrosis of the cerebral white matter (p = 0.003). Monochorionic multiple gestations frequently are complicated by antenatal necrosis of the cerebral white matter. Multiple vascular connections with vein-to-vein anastomosis appear as the most important associated factor for antenatal necrosis of the cerebral white matter in this population.
Twin-twin transfusion syndrome associated with acute polyhydramnios in one sac and severe oligohydramnios in the other, which characteristically is diagnosed between 18 and 28 weeks, is associated with a high mortality rate for the involved twins. Patients who are managed without intervention have essentially 100% perinatal mortality. Nineteen patients with this diagnosis were treated at Good Samaritan Medical Center over a 5-year period. Because of the known perinatal mortality and because of early experiences with the twin-twin transfusion syndrome, we began to actively intervene in such patients with various modes of therapy. As experience was gained, it was found that repeated therapeutic amniocenteses, if performed before severe maternal abdominal distention or labor, appears to be beneficial.
Ultrasonographic estimation of amniotic fluid volume is an important adjunct to assessment of fetal well-being. However, no single method has emerged as most predictive. Many ultrasonographers use subjective or single-pocket guidelines in evaluation of amniotic fluid volume. We therefore assessed the ability of a maximum-vertical-pocket technique to identify patients with abnormal volumes of amniotic fluid. A total of 1168 patients was studied. Oligohydramnios (n = 76) was defined as an amniotic fluid index less than 5th percentile for gestational age (70 to 98 mm). Hydramnios (n = 51) was defined when the amniotic fluid index was greater than 95th percentile (185 to 249 mm). The ability of the maximum-vertical-pocket technique to identify cases with oligohydramnios by amniotic fluid index was poor: sensitivity was 42% and positive predictive value was 51%. Fifty-eight percent of cases with oligohydramnios by amniotic fluid index had "normal" values according to the single-pocket technique. The correlation coefficient between amniotic fluid index and maximum vertical pocket was 0.51, R2 = 24%. The correlation between the maximum vertical pocket and amniotic fluid index was somewhat better in cases of polyhydramnios (r = 0.79, R2 = 62%), but the sensitivity, positive predictive value, and false-negative rates were high as in oligohydramnios. These data suggest that the maximum-vertical-pocket technique has adequate specificity but is a poor screening tool. The results demonstrate that use of gestation-specific norms for the amniotic fluid index identifies abnormal amniotic fluid volumes more efficiently than the single-pocket technique.
To investigate the recent suggestion that fetal hypoxemia and acidemia in polyhydramnios are secondary to raised amniotic pressure, 5 to 15 L of normal saline solution was infused intraamniotically at 100 ml/min in seven ewes. Amniotic pressure increased linearly by 1.0 +/- 0.013 (mean +/- SEM) mm Hg per liter infused. Infusion of 15 L produced a mean rise in amniotic pressure of 15.2 +/- 1.2 mm Hg (p less than 0.001) but no significant change in fetal pH, PCO2, PO2, fetal heart rate, or mean arterial pressure. A similar rise in amniotic pressure and lack of change in blood gas values occurred in two control ewes infused intraperitoneally. Rupture of the membranes occurred in two of three amnioinfusions of 15 L. We conclude that acute amnioinfusion raises amniotic pressure in sheep but does not alter fetal blood gas status.
The reported mortality for prenatally detected congenital diaphragmatic hernia is high. Polyhydramnios and presentation in early pregnancy have been suggested as high-risk factors adversely affecting outcome. We retrospectively reviewed 55 cases of congenital diaphragmatic hernia diagnosed prenatally in our unit. There was an overall mortality of 73%. The mortality in cases with presentation before 25 weeks' gestation was 74%, if the cases resulting in termination of pregnancy are excluded, compared with a mortality of 60% in those seen after this gestational age. Underdevelopment of left-sided cardiac structures was found to be a helpful prognostic factor. We were unable to confirm the predictive nature of hydramnios. Associated chromosomal anomalies were found in two fetuses and major congenital heart disease in nine. Although diagnosis before 25 weeks' gestation is associated with a higher mortality than in cases detected later, it is not universally fatal. If congenital heart disease and chromosomal anomalies are excluded and there is little or no evidence of left heart underdevelopment, the odds for survival will improve. This should be taken into account when the management of these cases is planned.
The role of nonsteroidal antiinflammatory drugs in human reproduction and reproductive disorders is reviewed. Nonsteroidal antiinflammatory drugs inhibit the biosynthesis of prostanoids and can cross the placental barrier into the fetal circulation. Nonsteroidal antiinflammatory drugs are the treatment of choice in primary dysmenorrhea and intrauterine contraceptive device-induced dysmenorrhea and menorrhagia. Nonsteroidal antiinflammatory drugs can be used for effective control of menorrhagia, preterm labor, and polyhydramnios and for prevention of preeclampsia, but larger definitive clinical trials are needed. Prostaglandin inhibition with some nonsteroidal antiinflammatory drugs appear promising in the relief of some premenstrual symptoms and in the prevention of postoperative pelvic adhesion formation, but more studies are needed in women. Whereas implantation and tubal mobility are mediated by local prostaglandins, the potential use of nonsteroidal antiinflammatory drugs to suppress prostaglandin in these reproductive processes for enhancing or reducing fertility warrants further studies. In the last 2 decades nonsteroidal antiinflammatory drugs have been used increasingly in the treatment of some reproductive disorders and are promising for many others.
OBJECTIVE: Our purpose was to investigate whether acute alterations of amniotic fluid volume affect uteroplacental perfusion. STUDY DESIGN: Three groups of patients of comparable gestational age were studied in a fetal medicine referral unit: (1) eight pregnancies with severe polyhydramnios because of twin-twin transfusion syndrome undergoing therapeutic amnioreduction, (2) seven with severe oligohydramnios undergoing diagnostic amnioinfusion, and (3) six control women having invasive procedures of similar duration without manipulation of amniotic fluid volume. Color Doppler imaging was used to measure uterine artery impedance index values and quantitative blood flow before and within 15 minutes of the end of the procedure. RESULTS: Quantitative flow measurements increased after amnioreduction (74% median increase of volume flow, range 22% to 329%, p < 0.01) and decreased after amnioinfusion (33% median decrease of volume flow, range 17% to 51%, p < 0.05). Impedance index values increased after amnioinfusion (25% median increase in pulsatility index, range 4% to 71%, p < 0.05) and did not alter with amnioreduction. There were no significant changes in the control group. CONCLUSION: Acute changes in amniotic fluid volume alter uteroplacental perfusion. In twin-twin transfusion syndrome amelioration in uterine flow may improve fetal condition and explain in part the success of serial amnioreduction therapy.
To determine the influence of pregnancy on the retinas of insulin-dependent diabetics, we assessed 53 diabetic women by retinal photography every six weeks throughout pregnancy and for six months post partum. Thirty-nine nonpregnant insulin-dependent diabetics of childbearing age served as controls. Of the 39 controls, 18 (46.2%) had retinopathy. Of the 53 pregnant women, 33 (62%) had retinopathy at the first examination and eight others (15%) developed it as pregnancy advanced, significantly increasing the prevalence of retinopathy during pregnancy to 77.4%. Progressive changes occurred as pregnancy advanced; microaneurysms moderately increased, hemorrhages appeared in 30 (56.6%), and soft exudates in 15 (28.3%). Four patients (7.5%) had neovascularization, one for the first time. The condition of all four deteriorated during pregnancy. Six months after delivery the background changes had regressed to control levels. Neovascularization showed some regression. Duration of disease was related to the development and progression of retinopathy; every pregnant patient who had had diabetes for ten years had retinopathy. Retinal hemorrhages or neovascularization were associated with increased infant morbidity. Hemorrhages and exudates behaved independently and were associated with different risk factors, but increased insulin requirements and polyhydramnios were important risk factors in the development of retinal hemorrhages. Low fasting blood glucose levels late in pregnancy were significantly associated with soft exudates.
We report our experience with 65 patients with congenital duodenal obstruction, 36 with intrinsic and 29 with extrinsic lesions. Seventeen patients had trisomy 21 syndrome. Eight pregnancies were complicated by polyhydramnios. The diagnostic features encountered, the operative procedures used, and the postoperative management regimes used are presented. Thirty-two of the 36 patients with intrinsic lesions and 28 of the 29 patients with extrinsic lesions survived. The data on the five patients who died emphasize the effect of multiple congenital anomalies and prematurity on survival. This review suggests that the surgical procedures available for treating patients with congenital duodenal obstruction are well established and yield predictably good results.
OBJECTIVE: The purpose of this study was to test the hypothesis that the rate of complications of pregnancy in women with insulin-dependent diabetes is higher than in nondiabetic women and is associated with poor glycemic control and microvascular disease. METHOD: Women who enrolled in a multidisciplinary program of diabetes in pregnancy prior to 20 weeks' gestation were included in the study and matched 1:2 by age, race and parity to a control group of nondiabetic women. Complications of pregnancy were retrospectively analyzed and compared between groups. The association of complications with glycemic control and microvascular disease was analyzed within the diabetic group. RESULT: Women with diabetes had significantly higher rates of pregnancy-induced hypertension (PIH), polyhydramnios, pyelonephritis, preterm delivery and meconium-stained amniotic fluid. Poor glycemic control, particularly during the first and second trimesters of pregnancy, was associated with all complications, except pyelonephritis. Microvascular disease was associated with PIH and preterm delivery prior to 34 weeks. CONCLUSION: Women with insulin-dependent diabetes are at high risk for complications of pregnancy. Glycemic control during the first and second trimesters may affect events later in pregnancy.
Intestinal obstruction is often diagnosed prenatally by ultrasound, providing an opportunity for prenatal counseling, genetic investigation, and planned delivery at a perinatal center. We describe a patient with typical features of fetal bowel obstruction, who was found at birth to have congenital chloride diarrhea. A 25-year-old white woman had marked polyhydramnios; multiple dilated, fluid-filled loops of intestine were seen in the fetal abdomen on prenatal ultrasound. However, postnatally, there was no evidence of bowel obstruction. The infant girl passed large amounts of watery stools, but tolerated feeds well. A rectal biopsy showed normal ganglion cells. On the fourth day of life her serum sodium and chloride were markedly decreased, and stool chloride levels were diagnostic of congenital chloride diarrhea. She was placed on sodium chloride and potassium chloride supplements, and her serum electrolytes normalized. Congenital chloride diarrhea is a rare, inherited condition caused by an abnormality of intestinal electrolyte transport. This case illustrates that it may present prenatally with a picture similar to that seen with intestinal obstruction.
The authors reviewed their experience with meconium peritonitis (MP) diagnosed in utero to define criteria for prenatal and postnatal management. Prenatal diagnosis was made by identifying abdominal calcification on serial ultrasound examinations in nine fetuses, between 18 and 37 weeks' gestation. Cases without associated bowel abnormalities were considered "simple MP" and those with bowel abnormalities were considered "complex MP." Five cases of simple MP were identified at 18, 23, 30, 34, and 37 weeks' gestation. These five fetuses were delivered at term and had normal abdominal examinations. Abdominal radiographs were obtained in three showing normal bowel gas patterns, and abdominal calcifications in only two. All five patients were fed uneventfully. Four cases of complex MP were identified at 26, 26, 31, and 31 weeks' gestation. All four fetuses had dilated loops of bowel. Two of the four had meconium cysts, one of which was associated with ascites and the other with polyhydramnios. Shortly after birth both infants with meconium cysts required ileal resection and ileostomy for ileal atresia and ileal perforation, respectively. The remaining two infants had no evidence of dilated bowel, meconium cyst, or ascites on postnatal radiograph and were fed uneventfully. These data suggest that only 22% of fetuses with a prenatal diagnosis of MP develop complications that require postnatal operation. Gestational age at diagnosis does not correlate with postnatal outcome. Fetuses with complex MP are at increased risk for postnatal bowel obstruction and perforation.
Amniotic fluid concentrations of immunoreactive prolactin were measured during the third trimester in 184 diabetic gravidas and correlated with concurrent levels of prolactin in maternal plasma. Prolactin measurements concorded with previously published estimates in normal gravid women and averaged 825 +/- 32 ng/mL (mean +/- SEM) in amniotic fluid and 168 +/- 6.5 ng/mL in simultaneously sampled plasma. Cross-sectional and longitudinal analyses indicated that the prolactin levels in amniotic fluid of pregnant diabetics declined significantly between weeks 32 and 40 of gestation, whereas plasma levels did not change consistently during the same interval. Mean values for amniotic fluid prolactin did not correlate with simultaneous prolactin concentrations in plasma, nor with maternal age, clinical estimates of polyhydramnios, amniotic fluid creatinine content, or lecithin/sphingomyelin (L/S) ratios or subsequent birth weight of the offspring. Clear-cut correlations with overall maternal glucose regulation could not be demonstrated. However, subtle effects may be operative since amniotic fluid prolactin displayed weak but significant correlations with concurrent levels of maternal plasma glucose, and mean values for hemoglobin A1c (HbA1c) but not with mean values for fasting plasma glucose (FPG). Amniotic fluid prolactin concentrations were significantly greater in patients with pregestational diabetes (White classes C, D, and F) than in women with gestational diabetes mellitus (GDM) (our classes A1, A2, and B1). The differences could not be accounted for by differences in metabolic regulation, maternal age, or weights of these two populations.(ABSTRACT TRUNCATED AT 250 WORDS)
Diagnosis of trisomy 18 was made in 2 fetuses late in pregnancy. Both pregnancies were complicated by polyhydramnios coexisting with fetal growth retardation. The significance of these findings, and the advantages and limitations of late prenatal diagnosis of fetal chromosomal abnormality are discussed.
In order to assess the contribution of antenatal diagnosis to the management of gastroschisis, the antenatal and postnatal data from 24 cases of gastroschisis observed between 1974 and 1990 were re-examined. The frequency of antenatal diagnosis (29%), polyhydramnios (21%), atresia of the small intestine (29%), length of pregnancy (36.6 +/- 2 weeks of amenorrhea), proportion of cesarean sections (21%), birth weight (2230 +/- 430 g) and the Apgar score after 5 min (9.0 +/- 1.5) were comparable to findings reported elsewhere. The overall mortality rate for the period studied was high (41%), and was not influenced by any antenatal parameter or by the mode of delivery; its recent fall (P = 0.01) is explained by the development of therapeutic methods. These results are consistent with other recent studies and suggest that antenatal diagnosis does not enable an accurate assessment of the prognosis to be made and has no major influence on the mortality rate in gastroschisis.