Volume 27, Issue 3

Three-dimensional (3-D) ultrasound plays an important role in obstetrics predominantly for assessing fetal anatomy. Presenting volume data in a standard anatomic orientation assists both ultrasonographers and pregnant patients to recognize anatomy more readily. Three-dimensional ultrasound is advantageous for the study of normal embryonic and/or fetal development, as well as providing information for families at risk for specific congenital anomalies by confirming normality. This method offers advantages in assessing the embryo in the first trimester as it is able to obtain multiplanar images through endovaginal volume acquisition. Rotation of the embryo and close scrutiny of the volume allow the systematic review of anatomic structures such as cord insertion, limb buds, cerebral cavities, stomach and bladder. Using this modality one can easily obtain the volumes of the gestational sac and yolk sac and can evaluate their relationship to prediction of pregnancy outcome. Three-dimensional power Doppler sonography has the potential to study process of placentation and evaluate the development of the embryonic and fetal cardiovascular systems. Three-dimensional ultrasound imaging in vivo compliments pathologic and histologic evaluation of the developing embryo, giving rise to a new term: 3-D sonoembryology. Rapid technological development will allow real-time 3-D ultrasound to provide improved and expanded patient care on the one side, and increased knowledge of developmental anatomy on the another.

We searched the literature for mean values of arterial cord blood pH at birth and their lower limits of statistical normality. An arterial cord blood pH, correctly sampled, measured, validated, and interpreted, provides the most objective and sensitive index for fetal hypoxemia during labor. We advise to sample both artery and vein from a clamped segment of the cord within 30 minutes after birth. In accordance with physiological and statistical evidence, it is proposed to classify arterial cord blood pH in three categories: normal (when > 7.11), abnormal (when < 6.99), and borderline (7.00–7.11). An abnormal pH indicates that the fetus was in a state of biochemical decompensation at birth. Disadvantages of routine measurement include extra work load and the lack of a universally agreed definition of normal or abnormal pH. The major advantage of routine measurement is to provide care-givers with immediate feedback on their care during childbirth and an opportunity to learn from that feedback.

The increase in blood viscosity during pregnancy reduces maternal-fetal blood flow, which can lead to fetal hypoxia and acidosis. These factors have been related to a reduction in fetal growth and to premature births. We carried out a longitudinal study of 36 normal-term gestations at different stages of the pregnancy. We analyzed the erythocyte deformability, the intraerythocyte viscosity and the plasma viscosity in the mother, as well as the relation of these parameters to fetal growth (biparietral diameter (BPD) and length of the femur), birthweight, gestational age at birth and the Agpar score. The results obtained were as follows: from weeks 25 to 36 of pregnancy (30.9 (SD 2 weeks)) there occurs a significant increase in maternal erythocyte rigidity (p < 0.05) (despite the compensatory decrease in intracellular viscosity). This increase is very significantly related to the fetal biparietral diameter (r= −0.50, p < 0.01), the length of the fetal femur (r= −0.48, p < 0.02), gestational age at birth (r= −0.73, p < 0.0001, birthweight (r= −0.63, p < 0.001) and the Agpar score 5 minutes after birth (r= 0.67, p < 0.001). Our conclusions are that the reduction in erythocyte deformability (which we attribute to alterations in the fluidity or elasticity of its membrane) and the factors that increase the aggregation capacity of the red cells (modulators of blood viscosity and of blood flow in the placental intervillous space) are risk factors for reduced fetal growth, lower birthweight and lower gestational age at birth. By avoiding maternal hematocrit levels higher than 36% we could improve uteroplacental perfusion, fetal growth and perinatal results.

Objective: To evaluate the impact of counseling on reproductive choices in seropositive women in South-Eastern Italy. Setting: University Hospital, Apulia region, South-Eastern Italy, tertiary referral center for high risk obstetrics and infectious diseases. Methods: Between March 1985 and December 1996, two hundred and twenty-five HIV-infected women, receiving treatment at our clinic for infectious diseases were enrolled. They were all regularly given treatment and counseling and their sexual partners, if negative, tested for HIV-1 antibodies. Their reproductive choices and their attitude toward pregnancy were recorded and analyzed. Results: Seventy-six pregnancies were observed during this period in 76 women. Twenty-one of these women (27.7 %) decided to terminate the pregnancy. Women that were intravenous drug users or with a longer history of known seropositivity were more likely to have a termination. A decreasing trend in the request of abortion was observed with time. Conclusions: The data show that the scenario of HIV-infected women is changing in our setting. As a consequence, many seropositive women deliberately choose to have a pregnancy and factors different from those we expect to be modified by the counseling influence their reproductive choice. They should be taken into account in the management of these women before and during pregnancy.

This study was undertaken to assess the usefulness of maternal serum human chorionic gonadotrophin, alphafetoprotein and maternal age in screening for fetuses with abnormal chromosomes in pregnant women aged 35 years and over. From 1989 to 1991, 1208 women seen at the National University Hospital had karyotyping procedures performed for maternal age > 35 years as well as second trimester serum samples taken for alpha-fetoprotein and human chorionic gonadotrophin. Sixteen (1.3%) chromosomal abnormalities were present. Using cut off risk levels of 1:250 and 1:384, the sensitivity of the analysis in screening for Down's syndrome pregnancies was 71.5% and 86% respectively. For the non Down's chromosomal abnormalities, using cut off risk levels of 1:250 and 1:384, the sensitivity of the analysis was only 22.3% and 33.4% respectively. Thus risk calculations based on the two serum markers and maternal age failed to identify all fetuses with abnormal chromosomes.

Objective: To determine any adverse outcome to infants born to mothers with Antiphospholipid Syndrome (APS). Design: Case control study with retrospective data collection and prospective pediatric review. Setting: Regional Recurrent Miscarriage Clinic based at a University Teaching Hospital. Participants: Infants (n = 62) of mothers with APS, compared to 124 index cases randomly selected from the delivery register, matched for gestation and sex who delivered between 1992 and 1997. Results: Sixty two infants born to 55 women with APS were reviewed to study the neonatal outcome. The prematurity rate for the group was 10%, compared to 8.5% for the total hospital population over the same period of time. Twenty-one percent (21%) had birth weights less than or equal to the 10th centile, which was not statistically significant compared to matched controls.

During pregnancy the role of the cervix shifts between two opposing functions. Throughout most of gestation, the cervix is rigid and resists tension in order to maintain the products of conception inside the uterus. At term, however, cervical function changes drastically in order to accommodate stretch and delivery. The events that control cervical function are not known. The aim of this study was to characterize changes in cervical resistance and collagen content during pregnancy in the rat. To determine the change in cervical resistance, non-pregnant and timed pregnant Sprague Dawley rats were sacrificed at various times. Their cervices were isolated and suspended in organ baths connected to a cervimeter for measurement of the stretch-tension relationship. In a different group of animals, cervical collagen content was measured using light-induced fluorescence in non-pregnant and, longitudinally, in pregnant rats. Cervical resistance and collagen content decreased progressively during pregnancy. The changes in cervical resistance mirrored those in cervical collagen content and the nadir in both occurred about two days prior to the onset of labor. Our study suggests that cervical preparation for delivery does not occur acutely at the time of labor and that cervical collagen content determines cervical resistance.

Background: To study maternal and fetal plasma levels of catecholamines (CA) during pregnancy and delivery, especially changes in CA levels during fetal distress and conditions of different modes of delivery. Methods: Maternal and fetal plasma NE, E and DA levels were determined by high performance liquid chromatography (HPLC) for 16 non-pregnant women, 19 cases of early pregnancy, 17 cases of mid pregnancy, late pregnancy, spontaneous vaginal delivery and 53 cases of cesarean section. Results: Plasma NE and DA levels decreased gradually with the advance of gestational weeks, and levels of plasma NE were significantly lower than those of non-pregnant women (P < 0.05). The levels of plasma CA in patients who had elective cesarean section were significantly lower than those who had vaginal delivery and emergency cesarean section (P < 0.01). However, CA levels of the cord artery in the vaginal delivery group were significantly higher than those in the cesarean section group (P < 0.01). Conclusion: Vaginal delivery is better than cesarean section for the newborn. If cesarean section is necessary, it is best for the newborn after onset of labor.

Background: The number of teenage pregnancies has increased throughout the world and these pregnancies are reported in association with a higher rate of maternal and fetal complications. Aim of the study: To evaluate the social surroundings; the results of ante-, intrapartum surveillance and perinatal outcome in adolescent pregnancies where mothers were below the age of 18. Methods: Between 1st January, 1991 and 31st December, 1996 there were 13 131 births at our department. During this period, 209 newborns were born of 207 adolescent mothers. We compared the data of adolescent mothers with the data of all mothers who delivered in Hungary during the study period. Results: 39 (18.6%) from 209 newborns were delivered before 37th week of gestation, and 34 (16.3%) newborns showed signs of intrauterine growth retardation (IUGR). The rate of primiparous adolescent mothers was 72.0%, 131 (63.3%) were primigravidae, and 136 (65.7%) received adequate prenatal care. Maternal complications (pregnancy induced hypertension, threatened preterm delivery, gestational diabetes and pretal eclampsia) and adverse perinatal outcome (higher rate of IUGR and perinatal mortality) were found more frequently in adolescent pregnancies. Conclusions: As young maternal age is associated with an increased risk of unfavourable fetal outcome, teenage mothers need improved prenatal care and increased observation during labour. In addition, improvement of the social environment of adolescents and the prevention of teenage pregnancies should be recommended.

Controversial findings in numerous studies involving physiological and endocrinological parameters indicate that physical exercise during pregnancy is complex and somewhat poorly understood. But despite this reservation, it is safe to say that on the basis of the current state of scientific research in this area, physical exercise is to be recommended during pregnancy so long as women are aware of potential dangers and contraindications. Due to thermoregulatory advantages, the beneficials effects of immersion and its joint protective character “aquatic exercise” can be highly recommended during pregnancy. Psychologically speaking, physical exercise offers a variety of benefits such as the encouragement of cooperation and competition which can be experienced as fun and gratifying. The physiological and psychological benefits of physical exercise are not only available to healthy women, but have also proven to be valuable for the prevention and treatment of illnesses such as gestational diabetes. The activation of large groups of muscles allow for an improved glucose utilization by simultaneously increasing insulin sensitivity.

We studied the possibility of an etiological role for endothelin-1 (ET-1) in the development of persistent pulmonary hypertension of the newborn (PPHN). Ten infants with severe PPHN requiring extracorporeal membrane oxygenation (ECMO) were studied. Pre and post pulmonary blood samples were obtained on commencing ECMO and on recovery. The samples were analyzed by radio-immunoassay. The infants with PPHN requiring ECMO had a significantly higher mean ET-1 concentration (21.1 pmol/l, S. D. 3.59) than a group of healthy controls (16.6 pmol/l, S. D. 4.44); however 8 of our 10 infants had individual ET-1 levels within our reference range for healthy newborns. Pre and post pulmonary ET-1 levels did not differ significantly and there was no evidence of a decline in ET-1 levels with resolution of PPHN. Pulmonary overproduction of ET-1 does not appear to be the cause of PPHN, although the endothelin system may still play a role in the pathophysiology of PPHN, probably mediated through changes in receptor expression.

Objective: To study the maternal and neonatal outcome of twin pregnancies complicated by the intrauterine death of one fetus after 20 weeks of gestation. Design: Retrospective, observational study of 7 twin pregnancies out of 185 twin pregnancies with the diagnosis of a single intrauterine death over a 5-years period in a university hospital. Results: The incidence of single fetal death in twin gestation after 20 weeks was 3.8% in the study population with a high incidence of intrauterine growth retardation (IUGR) of the remaining fetus and preeclampsia in the further course of pregnancy. The incidence of preterm delivery was 71% with a mean gestational age of 33.0 ± 1.0 weeks. The median interval from diagnosis of single fetal death to delivery was 10.2 ± 4.1 days (range 1–28 days). 5 of 7 (71 %) cases were delivered by cesarean section for standard obstetrical reasons. Neither perinatal nor neonatal death of the remaining twin were observed. Two cases of neurologic injury were diagnosed after delivery by ultrasound and MRI. No maternal coagulopathy related to single fetal death occured. Conclusion: Expectant management of single fetal death in twin pregnancies might be advisible under close surveillance of both, mother and the surviving fetus.

The case of a newborn male infant with congenital Langerhans cell histiocytosis (LCH) is presented. At birth, showed cutaneous lesions (papules and vesicles with a haemorrhagic aspect), mucosal and ganglionic involvement. Biopsy of these lesions led to the diagnosis of LCH. At 24 hours of life the patient began with respiratory, hepatic, hematological and renal dysfunction, and died at 72 hours of life, despite corticoid treatment. LHC with vesicles and a rapid and fatal development, has previously only been described in three patients. The differential diagnosis of a disseminated and hemorragic vesicular eruption in a newborn infant is extensive and must include LHC.

Objective. To assess the efficacy of rectally administered gemeprost pessaries in the tretament of severe postpartum hemorrhage. Design. Retrospective analysis of a twelve month period in which all patients having postpartum hemorrhage treated with rectal gemeprost were analyzed. Setting. Royal Darwin Hospital, Northern Territory, Australia. Population. Fourteen women with established postpartum hemorrhage not responding to oxytocine and ergo-metrine regimens, or not responsive to oxytocine and having contraindications to ergometrine. Main outcome measures. Per vaginum bleeding with continued postpartum hemorrhage; adverse patient reactions to gemeprost; need for operative intervention. Results. All patients who were treated with rectally administered gemeprost pessaries had cessation of bleeding per vaginum. There were no adverse side effects noted from the medication and no patient required surgical treatment. Conclusions. Rectally administered gemeprost administered pessaries appear to be safe and effective method of treating severe postpartum hemorrhage in those patients in whom the standard oxytocic regimens fail. This form of treatment may avoid the need for parenteral prostaglandins or surgical intervention.