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One hundred and seventy-six amniocenteses were performed in the Johannesburg Amniocentesis Clinic in 1976. These were for genetic studies, assessment of fetal lung maturity and assessment of the severity of rhesus disease. The indications for amniocentesis and the results are discussed. The overall complication rate was low. This was due to certain precautions and approaches taken, which are detailed.
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A review of the literature indicates a small but significant incidence of fetal-maternal hemorrhage following amniocentesis. In these studies, consideration has not been given to the frequency with which erythrocytes containing hemoglobin F are to be found in the maternal circulation in the absence of amniocentesis. In this investigation, Kleihauer-Betke analysis was carried out before and after amniocentesis. This study confirms previous reports that spontaneous fetal maternal hemorrhage is not uncommon during normal intrauterine gestation and that amniocentesis is probably only an occasional cause of fetal-maternal hemorrhage. This impression is based on the findings that most Kleihauer-positive maternal blood samples after amniocentesis were also positive before amniocentesis. In spite of these findings, and since Rh-immune serum globulin is apparently harmless to the fetus and mother, its use is still advocated in nonsensitized Rh-negative mothers after amniocentesis.
A total of 2702 transabdominal amniocenteses performed at the Los Angeles County--University of Southern California Medical Center were reviewed, with particular emphasis on 392 samples performed beyong 41 weeks' gestation. A significant rise in the percent of amniocenteses with meconium staining was found to occur at an beyond 39 weeks. Meconium-stained fluid at amniocentesis was found to be associated with an increased incidence of babies weighing greater than 4000 g, maternal diabetes mellitus, and cesarean deliveries, in comparison to samples with clear amniotic fluid. Infants with meconium-stained fluid had an increased incidence of low 1-minute Apgar scores, but all 5-minute Apgar scores were 7 or greater. Ten perinatal deaths occurred after an amniocentesis with clear fluid in prolonged pregnancy, with four of these occurring within 7 days of amniocentesis. Lecithin/sphingomyelin (L/S) ratios less than 2.0 were found in 6% of amniocenteses performed beyond 41 weeks. However, none of the newborns with low L/S ratios develop subsequent neonatal respiratory distress syndrome. Amniotic fluid creatine values or blood-contaminated fluid were not found to be correlated with fetal outcome. No fetal mortality was attributable to amniocentesis. In view of the significant amount of false-positive and false-negative results, and the rare inherent danger associated with amniocentesis, its use solely to demonstrate the presence or absence of meconium staining appears to be of questionable value in the management of prolonged pregnancy.
Anxiety was measured and compared in three groups of 12 pregnant couples undergoing amniocentesis for prenatal diagnosis of chromosomal disorders. Significant elevations in anxiety were found in all groups prior to counseling on the day of the procedure and prior to receiving test results. Women who had previously given birth to a child with a chromosomal disorder displayed higher anxiety levels prior to amniocentesis than women whose indication for the procedure was age. Fathers in the previous trisomy group had higher anxiety levels prior to the receipt of test results as well as before the amniocentesis when compared to fathers in the maternal-age group. An experimental group of couples in which the women were over 35, received weekly calls from the genetic counselor. This intervention did not reduce median anxiety scores significantly for either men or women but did lower anxiety among the minority of extremely anxious mothers. Parental anxiety levels were interpreted based on interview data. Conditions which promote anxiety were contrasted to those which diminish it. Suggestions were made for amniocentesis counseling earlier in pregnancy and for identifying parents who would benefit by extra attention from counselors.
In 139 patients for prenatal diagnosis 186 amniocenteses were required. The repetiion of amniocentesis followed in 12.3% due to failure of cell growth, in 1.1% due to failure to obtain fluid, and in 10.2% to performe the fetography. In 3 pregnant women 2 repetitions were indicated. Although the amniocentesis were performed without ultrasound, in 92% the first insertion of needle were already succeeded in obtaining fluid. In repeated amniocenteses no significant differences were found. Brownish fluid were observed in 4.7% of the first amniocentesis. With 24.4% it was significantly more frequent in the repeated amniocenteses. Bloody taps appeared in each fifth puncture, but only in 2.8% blood fluid were also withdrawed for cell culture. 82.9% of the first amniocentesis followed between 16 and 19 week's gestational age and the result was present after 20.3 days on an average. The abortion rate was 4.3%. Among the newborns one hydrocephalus with questionable needle mark, one microcephalus and one further child with questionable needle mark were found. In one duodenal atresia and in one achondroplasia an inconclusive result was obtained. Two erroneous diagnoses of sex occurred and no diagnosis was obtained in two women.
With the increased use of routine ultrasonography at the time of genetic amniocentesis, twins are increasingly likely to be discovered at the time when the procedure is to be carried out. In the presence of twins the likelihood of finding an abnormality may be significantly increased, but at the same time problems such as discordance between the twins for the abnormality, or the inability to test both twins may occur. This altered situation may affect the parents' decision as to whether or not to undertake amniocentesis, and the need for additional counseling prior to proceeding with the amniocentesis is stressed.
Since 1972, we have performed 951 early amniocentesis in 902 pregnant women. There were 19 twin pregnancies, all diamniotic, representing 2.1% of the sample. Diagnosis was always suspected before the amniocentesis. It was confirmed by echography in the 14 cases in which this technique was used. Out of the first 5 cases without echography, we punctured only one sac. In the 14 last cases, the process was successful in 13 cases thanks:--the perfection of echography showing the exact location of the fetuses and the position of the septum--the injection of congo red (12 cases) or methylene blue (2 cases) into the first sac. The indications were as follows: chromosomal aberrations (14 cases) metabolic diseases (1 case), sex-linked disorders (1 cases) neural tube defects (3 cases). No complications due to amniocentesis were observed but three abortions and one fetal death occurred. The reason why is discussed. We have made only one therapeutic abortion.
212 amniocentesis were performed at the Gynecological Clinic of the University Graz in cooperation with the Institute for Human Genetics of the same University from 1.7.1974 to 1.4.1978 for prenatal detection of genetic disorders or inherited disorders of metabolism. In 9 cases (4,2%) pathological results or special chromosomal aberrations were found. Five pregnancies (2,3%) had to be interrupted with prostaglandins. One case of Down-Syndrome ended by spontaneous abortion. Three women had a miscarriage following amniocentesis up to 6 weeks afterwards. In two cases (0,9%) a primary connection of puncture and loss of pregnancy could be documented. 4 cases (1,8%) suffered of amniotic fluid leakage after amniocentesis. Three patients delivered healthy term babies. This study demonstrates the high accuracy of the described diagnostic procedures.
A prospective study was conducted to evaluate the usefulness of amniocentesis in patients with premature rupture of membranes (PROM) for the prediction of occult or impending intrauterine infection and the assessment of fetal maturity. Fifty-nine patients with PROM between 28 and 35 weeks' gestation, without apparent infection, were evaluated sonographically for possible amniocentesis. Thirty patients had successful amniocenteses for a success rate of 51%. Fifteen patients had a mature lecithin/sphingomyelin (L/S) ratio and were delivered immediately without respiratory distress syndrome (RDS) or other neonatal complications. All amniotic fluids were evaluated by Gram stains and cultures. Nine of the 30 patients had positive cultures, with a high incidence of subsequent development of amnionitis and other infectious morbidity. In the 21 patients with negative cultures, there were 19 without any infectious morbidity. Amniocentesis appears in this study to be a useful method for selecting the patients who have mature fetuses and/or who are more likely to develop amnionitis.
Anxiety state and trait were measured before and after amniocentesis early in the second trimester of pregnancy, in a group of 28 women who were at risk of bearing an abnormal foetus. A significant decrease in maternal anxiety occurred in the majority of women after receiving the results of the amniocentesis. It is concluded that amniocentesis for intrauterine diagnosis of foetal abnormalities makes a significant contribution to the psychological wellbeing of those pregnant women who are at greater risk of having an abnormal baby.
The authors analysed 1061 early amniocentesis carried out during 1000 pregnancies. The indications were as follows: chromosomal abnormalities (79,6 p. 100), fetal karyotypes for X-linked diseases (4,7 p. 100), metabolic disorders (5,9 p. 100), amniotic fluid alpha-foetoprotein (9,8 p. 100) in neural tube defect or congenital nephrosis. Amniotic fluid was obtained on the first attempt in 98.2 p. 100 and on the second attempt in 100 p. 100. The fluid was heavily blood-stained in 1,7 p. 100, sanguinolent in 3,8 p. 100 and brownish in 2,40 p. 100. Cells were grown on the first attempt in 98 p. 100 and on the second attempt in 100 p. 100. The outcome of pregnancies was correlated with the indications of amniocentesis. The rate of spontaneous abortion is 1,7 p. 100, but only 6 of them can be due to amniocentesis (0,6 p. 100). Perinatal mortality was 1,8 p. 100: mortinatality (1,2 p. 100) and neonatal mortality (0.6 p. 100). All this fetal deaths have other causes. The fetal loss was 3,9 p. 100. Fetal morbidity was low: none fetal injuries, none cutaneous scar, few premature deliveries (1,6 p. 100), some malformations more or less serious (2,6 p. 100) with 4 congenital luxations of the hips (0,45 p 100). Maternal morbidity was limited at a greater cesarean section rate: 21 p. 100 (30 p. 100 in women 40 years old and more), none feto-maternal rhesus immunization was observed because immunoprophylaxis was strictly performed. The rate of therapeutic abortion was 4,6 p. 100 without any diagnostic error. Diagnostic accuracy was 100 p. 100. Several conditions are necessary to be the procedure safe accurate and reliable: appropriate genetic counseling, exact determination of gestational age (17 international weeks), sufficient volume of amniotic fluid counseling, exact determination of gestational age (17 international weeks), sufficient volume of amniotic fluid (uterus size: 12 cm), gynecologic examination by operator himself, perfect echography to localize the placenta and detect multiple gestations, adequately trained obstetrician, use of 20 gauge spinal needle, stric asepsis, experimented laboratory and experienced staff.
In three of 111 infants born after amniocentesis and in one of 5 fetuses aborted after amniocentesis, which could be examined, small skin lesions or scars were observed. Interpretation as sequelae of needle puncture appears possible, but questionable, particularly since similar lesions were observed in infants born after uncomplicated pregnancy without amniocentesis. The differential diagnosis of a focal dermal hypoplasia or aplasia may be considered, which may be hereditary.
In 14 twin pregnancies amniocentesis was performed for prenatal detection of genetic disorders. The indications, technique of amniocentesis under control of ultrasound, results and the outcome of pregnancies were described. In all cases with two amniotic-sacs a separate amniocentesis was possible. The prenatal diagnosis was always proved after delivery.
Ten cases of severe fetal heart rate deceleration following maternal vaso-vagal reflex during amniocentesis were presented. The good outcome of these fetuses suggests that this transient phenomenon has no adverse effect on the fetus. This type of FHR response should be recognized so as to avoid unnecessary Caesarian sections done because of severe FHR bradycardia following amniocentesis.
To determine the effect of development of ultrasonographic guidance techniques on the frequency of amniocentesis, we compared two two-year periods before and after the use of ultrasound. Statistically significant decreases in both the number of amniocenteses ordered and the number performed were observed. We concluded that ultrasound has been judiciously used and has not prompted an increased use of amniocentesis merely because of improved ease and safety. A slight decrease in the perinatal mortality rate mitigates against any compromise in the standard of antenatal care.
The role of amniocentesis in producing fetal malformations has been investigated in the rat. Relevant uterine contractions were observed after amniocentesis. The pathogenetic mechanism of fetal malformations is discussed on the basis of the present results.
A case of fetal exsanguination after midtrimester genetic amniocentesis is reported. Examination of the ration of fetal-to-meternal red cells in the amniotic fluid obtained by amniocentesis for genetic study from 242 consecutive patients, including the reported case, suggests that fetal hemorrhage is relatively common and difficult to avoid during this procedure. It also appears that hemorrhage occurs significantly more oftern when the placenta is located anteriorly. Reasons as to why the accident is rarely fatal are considered, and some recommendations for patient counselling and management are discussed.