Volume 27, Issue 4

Aims: The purpose of this study was to assess the effect, if any, of color Doppler on the measurement of the amniotic fluid index in term pregnancies. It is hypothesized that color Doppler may enhance the detection of oligohydramnios. Methods: The amniotic fluid index was performed with and without color Doppler on pregnancies greater than or equal to 36 weeks gestational age. Differences in the mean amniotic fluid index measurements were assessed. The incidence of oligohydramnios was examined using both techniques. Differences in continuous variables were assessed with the paired t test, differences in categorical variables were assessed using the Fisher Exact Test. Results: There were 155 pregnancies examined, the amniotic fluid index was significantly decreased when color Doppler was added to the standard technique. (P < .0001) The incidence of oligohydramnios was higher with the application of color Doppler to the standard amniotic fluid index. (P < .05) Conclusions: Color Doppler results in a significantly lower amniotic fluid volume measurement and may enhance the detection of oligohydramnios.

This is a retrospective study of McDonald cerclages comparing absorbable suture v. nonabsorbable suture and showing no adverse outcomes associated with the absorbable cerclage group. Objective: To compare the efficacy of traditional nonabsorbable suture to delayed absorbable suture for use in McDonald cervical cerclage. Study design: A retrospective analysis was conducted examining all cerclage procedures over a one year interval, from 7/01/97 until 6/03/98. Cases were stratified by the type of suture material, specifically nonabsorbable versus delayed absorbable. Demographic data, as well as selected perinatal outcomes were analyzed for each group. Statistical analysis was performed using Chi-square and Fishers Exact test for categorical data, and the Student t-test for continuous variables. A p < .05 was considered statistically significant. Results: Eighteen patients who underwent a McDonald cerclage were analyzed. In fourteen a nonabsorbable cerclage was utilized and in four an absorbable cerclage was used. The mean gestational age at delivery for the nonabsorbable suture group was 36.9 weeks compared to 39.2 weeks for the patients receiving an absorbable cerclage (P = 0.2). The mean birth weights for each group were 2732 ±183 gms and 3616 ±343 grams, respectively (P =0.04). Conclusion: Based on our findings delayed absorbable suture material may be a reasonable alternative during cerclage placement, with the added benefit of spontaneous degradation versus surgical removal.

We present a case of mid pregnancy loss with retained intrauterine contraceptive device associated with fetal Candida infection. Review of English literature identified 53 additional cases of fetal candidal infection, with 17 associated with an IUCD in situ. The presence of an IUCD was associated with delivery at a statistically significant earlier gestational age when compared to cases not associated with an IUCD (23.3 ± 4.9 vs 31.6 ± 7.0, p < 0.001). Seventy-seven percent of fetal candidal infections associated with an IUCD were systemic (heart, brain, liver, gastrointestinal, lung) compared to 33% of cases not associated with an IUCD. In contrast to bacterial intraamniotic infections there was a low incidence of maternal febrile morbidity. An hypothesis as to the pathogenesis of Candidal infections in the presence and absence of an IUCD is offered as well as a paradigm for the management of the gravid patient with an IUCD in situ.

Aims: A multisite study of term and near term infants readmitted in the first two weeks of life to 9 New York City area hospitals in 1995 was conducted to evaluate factors related to readmission, including length of newborn stay. Results: Of the 30,884 infants born at the 9 study hospitals 391 newborns were readmitted. The major admission diagnoses were infection, 40.7 %, hyperbilirubinemia, 39.1 %, and feeding and/or gastrointestinal problems, 10.5 %. In the first week, 65.1% of readmissions were for hyperbilirubinemia and 19.1% were for infection or suspected sepsis. In the second week, 67.8% of readmissions were for infection and 7.6% were for hyperbilirubinemia. Hyperbilirubinemia was the most frequent diagnosis for White and Asian infants, while infection was most frequent for African-American and Hispanic infants. Age at readmission was younger and the interval from discharge was shorter for infants with hyperbilirubinemia. Abnormalities which should have precluded early discharge included feeding difficulties, cyanotic congenital heart defects, hemolytic disease of the newborn, early jaundice or early high bilirubin levels. Conclusion: Attention to identification of infants at risk and programs such as lactation counseling and universal screening for bilirubin (with appropriate interpretation) prior to discharge could have reduced the necessity for readmission regardless of the newborn length of stay.

We report an unusual case of the left sided diaphragmatic hernia in which the left lobe of the liver blocked the herniation of the intestinal contents into the chest and the clinical symptoms were not apparent at birth. The patient was a full term infant born to a mother whose antenatal care included apparently normal sonographic evaluation. She developed increasing tachypnea within two hours period after birth. Auscultation of the chest revealed bilateral normal aeration. No cardiac murmurs were heard. An X-ray of the chest revealed a left sided haziness without any mediastinal shift. Progressive decrease in the breath sounds was noted over the left base. A CT examination demonstrated a left sided diaphragmatic hernia, with herniation of the left lobe of the liver causing compression of the lung. No loops of the bowel were observed in the thoracic cavity. She underwent laparotomy and repair of diaphragmatic hernia. This case history illustrates that large left sided diaphragmatic hernias may be missed on antenatal sonogram and may not present with clinical signs until several hours after birth. Both physical examination and routine chest X-ray may prove inconclusive and a CT scan is necessary to make a definitive diagnosis.

Our objective was to study the development of experimental brain ischemia and hemorrhage by real-time optical imaging. Optical imaging is based on the ability of near infrared light to non-invasively penetrate through the intact scalp and skull and measure brain concentrations of oxy- and deoxyhemoglobin, dominant brain absorbers. Optical imaging was performed in 7 anesthetized, instrumented, and ventilated newborn piglets subjected to the injection of 0.3 cc of saline followed by 2 cc of blood into the left frontal subcortical brain region via a needle inserted through the skull with stereotactic guidance. The image-acquisition rate of 5.26 images per sec allowed for real-time imaging. The detection threshold of the imager at the estimated depth of 1–1.5 cm was ∼, 70 μL for saline and ∼,40 μL for blood. The imager readily detected five subcortical hematomas and two large bilateral subarachnoid hemorrhages. The imager detected a global decrease in brain absorption associated with the volume-injection-related increase in intracranial pressure in the surrounding ipsi- lateral and contralateral brain. Any decrease in brain absorption is an equivalent to brain ischemia. This study demonstrates the capability of optical imaging in detecting brain ischemia and hemorrhage in real-time with high temporal and spatial resolution.

Objective: The purpose of the study was to determine EKG and 2-D echocardiographic criteria of ventricular dominance in preterm infants and select those by which ventricular dominance could be established by EKG alone. Methods: A database was constructed from EKG and 2-D echocardiographic measurements on preterm infants ranging in gestational ages from 23 to 34 weeks and birth weights from 555–2490g, and fullterm controls. Twelve-lead EKGs were obtained in the first 4 days of life in 12 preterm infants and in the first 24 hours of 4 controls. 2-D echocardiograms were performed with sweeps from the subcostal, parasternal, apical and suprasternal views and M-mode measurements in the short axis parasternal view on 11 of the preterm infants and 9 fullterm controls. Results: A definite leftward QRS axis for the preterm infants (+19°, preterm; +133.75°, term; t = −5.63; p < 0.001) indicated a left ventricular (LV) dominance. But R/S in favor of LV dominance for preterm infants was apparent in V 6 only. A pooled amplitude index for each ventricle based on R and S wave from V 1 , V 2 , V 5 , and V 6 leads, showed LV dominance for the preterm infants with a trend toward RV dominance with increasing gestational age (F = 20.82; p < 0.001). RVD/LVED M-mode echo ratios confirmed the LV dominance in preterm infants. Conclusion: A healthy full term infant is born with RV dominance. LV dominance with a trend toward RV dominance with increasing gestational age was found in preterm infants by EKG and echo criteria.

Congenital aortic stenosis accounts for about 5% of cardiac malformations recognized in childhood. It belongs to the category of acyanotic congenital heart disease. These lesions produce a load on the heart because of left ventricular outflow tract obstruction. Severe aortic stenosis in the newborn period (critical aortic stenosis) presents with signs of left sided heart failure (pulmonary edema, poor perfusion), right sided heart failure hepatomegaly, peripheral edema) and may progress rapidly to total circulatory collapse. We present a case of an infant with critical aortic stenosis presenting with cyanosis, who was entirely dependent on ductal patency for systemic output. When oxygen was given, the ductus started to close, with a worsening of the left sided output and subsequent acidosis. With the right to left shunt across the ductus, the baby was cyanotic and dependent on prostaglandin to keep the ductus open. There was minimal flow across the aortic valve because of the stenosis and extremely poor left ventricular function prior to surgery. After relief of the aortic valvular obstruction, there was finally good antegrade flow across the aortic valve, terminating cyanosis.

Aims: To identify pre- and perinatal risk factors for Tourette disorder. Methods: Case control study. We matched names of patients who met DSM criteria for Tourette disorder with their birth certificates. For each case five controls were selected. The controls were matched by sex, year and month of birth. Results: Univariate analysis of the 92 cases and the 460 matched controls identified 4 risk factors; one categorical variable–trimester prenatal care begun and 3 continuous variables 2 apgar score at 5 minutes, month prenatal began and number of prenatal visits. Logistic modeling to control for confounding produced a three variable model (apgar score at 5 minutes (OR 5 1.31), number of prenatal visits (OR 5 .904) and fathers age (OR 5 .909). The model parameters were: χ 2 5 19.76; df 5 3; p < .001. Conclusions: This is an inexpensive methodology to identify potential risk factors of patients with Tourette disorder and other mental illness.

Objective: To assess the diagnostic potential of Magnetic Resonance Imaging (MRI) in the management of ultrasonically diagnosed congenital anomalies. Patients and Methods: Ninety-two patients were included into the study after the ultrasonic diagnosis of an abnormality. Sixty-three of these patients were affected by an abnormality of the central nervous system (CNS) and 29 by abnormalities in other apparatuses. The GRE technique was used to obtain T1 and T2 star-weighted images. Results and Discussion: Satisfactory imaging was obtained in all but one case. In order to define the "reliability" of MRI for a given condition, a diagnostic score was designed and separately given by the obstetrician and the radiologist involved in the case. MRI scored less than ultrasonography for abnormalities of the fetal contour and for large and complex distortion of the CNS as holoprosencephaly. For subtle midbrain anomalies, as well as for neuronal migration disorders, MRI definitely was superior to sonography. For other anomalies, as for example congenital diaphragmatic hernia, MRI was better than conventional techniques in assessing prognosis and outcome, but less reliable in assessing associated anomalies. MRI seems to be a valuable adjunct to us for prenatal diagnosis of only selected fetal anomalies and requires precise guidelines in a multidisciplinary approach to prenatal pathology.

Our purpose was to elucidate why clinical studies have up to now failed to demonstrate a positive effect of TRH combined with glucocorticosteroids on fetal lung maturity. Morphological and biochemical lung maturation were determined by electron microscopy, choline incorporation, and surfactant-protein-A m-RNA synthesis in rat lung organoid cultures after exposure with a series of concentrations of dexamethasone, triiodothyronine, and dimethyl-isopropyl-thyronine. Thyroid hormones improved morphogenesis of lung histotypic structures but had a negative effect on surfactant synthesis whereas glucocorticosteroids had a positive effect on the surfactant synthesis but a negative effect on morphogenesis. The combination of both substances even had the most negative effect on morphogenesis. Since morphogenesis of lung histotypic structures is prerequisite for surfactant synthesis and secretion, we hypothesize that a sequential treatment of thyroid hormones to improve morphogenesis followed by the application of glucocorticosteroids might be an option to improve neonatal lung function.

Two hundred and fifty women, underwent endovaginal sonography in the first trimester to establish the normal size and shape of the secondary yolk sac and to assess the value of yolk sac evaluation in predicting poor pregnancy outcome. We calculated the correlation coefficients between yolk sac and menstrual age, yolk sac and crown-rump length and between yolk sac and mean gestational yolk sac diameter as r: 0.9581 (p < 0.001), r: 0.9427 (p < 0.0001) and r: 0.8855 (p < 0.0001), respectively. Of 250 cases, 219 had a normal pregnancy course through the end of the first trimester (Group I) while 31 had a poor prognosis such as abortion or embryonic demise (Group II). Eight of 219 in Group I and 20 of 31 in Group II had an abnormal yolk sac size. A yolk sac diameter out of two standard deviations of the mean for the menstrual age allowed prediction of an abnormal pregnancy outcome with a sensitivity of 65 %, a specifity of 97 %, a positive predictive value of 71 %, and a negative predictive value of 95 %. Ten of 219 and 9 of 31 had abnormal yolk sac shape. An abnormal yolk sac shape allowed prediction of an abnormal pregnancy outcome with a sensitivity of 29 %, a specificity of 95 %, a positive predictive value of 47% and a negative predictive value of 90.5 %. We concluded that secondary yolk sac evaluation is a valuable tool to predict pregnancy outcome.