Volume 31, Issue 3

Antepartum fetal surveillance is routinely used to assess the risk of fetal death in high-risk pregnancies. Traditionally, testing is performed in the hospital or outpatient clinic by trained medical staff. New equipment is now available that is easy to operate and can be used for selfmonitoring of the fetal heart rate (FHR) in the home setting. The tracings are transmitted by modem to a referral center for immediate interpretation by a health provider. The aim of this review was to assess the current data on the application of this new technology with regard to feasibility, access to care, maternal and neonatal outcome, patient and physician satisfaction, and cost-effectiveness.

Objective: To investigate maternal-fetal outcome of infants born after pregnancies complicated by (H)ELLP syndrome. Study design: A retrospective cohort study was performed on patients with the HELLP or ELLP syndrome. Maternal and perinatal complications were recorded. The follow-up period of the infants was at least 18 months. A multivariate regression analysis was done to define the variables mostly contributing to adverse outcome. Results: No maternal deaths occurred. Eighteen infants of the HELLP group and six infants of the ELLP group died; total perinatal mortality was 17.6%. After 18 months four infants had major handicaps, making a total adverse outcome of 22.8%. Statistical analysis shows early gestational age, prolongation of pregnancy and administration of antihypertensive medication as the factors influencing outcome of the infants most. Conclusions: Prolongation of pregnancy contributed to better perinatal outcome, while administration of antihypertensive medication and early gestational age were related to a more unfavorable outcome.

Objective: An extensive study as to whether maternal age itself is a risk factor for blood loss during parturition. Method: A total of 10,053 consecutive women who delivered a singleton infant were studied.The excess blood loss was defined separately for women with vaginal and cesarean deliveries as ≥= 90th centile value for each delivery mode. The effects of 13 potential risk factors on blood loss were analyzed using multivariate analysis. Results: The 90th centile value of blood loss was 615 ml and 1,531 ml for women with vaginal and cesarean deliveries, respectively. A low lying placenta (odds ratio[OR] , 4.4), previous cesarean (3.1), operative delivery (2.6), leiomyoma (1.9), primiparity (1.6), and maternal age ≥= 35 years (1.5) were significant independent risk factors for excess blood loss in women with vaginal delivery. Placenta previa (6.3), leiomyoma (3.6), low lying placenta (3.3), and maternal age ≥= 35 years (1.8) were significant independent risk factors for excess blood loss in women with cesarean sections. Conclusion: A maternal age of ≥= 35 years was an independent risk factor for excess blood loss irrespective of the mode of delivery, even after adjusting for agerelated complications such as leiomyoma, placenta previa, and low lying placenta.

Objective: Our study analyses the emotional mood of pregnant women and their partners before various prenatal diagnostic procedures (amniocentesis, ultrasound, chorion villus sampling), and their psychological stress both before and after the diagnostic procedures. Methods:We studied 472 pregnant women and 308 partners. 88 women (18.6%) had an amniocentesis, 344 (72.8%) had ultrasound and 40 (8.5%) a chorionic villus sampling. The German version of the Center for Epidemiological Studies-Depression Scale of Hautzinger and the short questionnaire of actual situative perceived stress of Müller were used. Results: Before prenatal examination, the mean level of depression and strain was equal in women and men in all groups (ultrasound, amniocentesis, chorionic villus sampling). Before the start of the prenatal examination the pregnant women had a significantly higher depressive feature on the depression-scale and significantly higher stress score than their partners. After prenatal examination the couples stress differed significantly in the three groups for women and for men. Comparing the stress experienced before and after the prenatal diagnosis revealed both for women and men statistically significant differences. Discussion: The individual experience of prenatal diagnosis is not determined by the invasivity of the procedure.

Aims: To evaluate the accuracy of sonographic estimation of fetal weight (EFW) in diabetic pregnancies and pregnancies with suspected fetal macrosomia. Methods: 63 women with diabetic pregnancies, 74 nondiabetic women with suspected largeforgestationalage (LGA) infants, and 161 controls underwent ultrasound assessment prior to induction of labor. EFW was compared to the weight at birth, 1–3 days later. Results: EFW was highly correlated to birth weight. Absolute or actual weight differences between the birth weight and the EFW, and the rate of EFW within 10% of birth weight were not different between the groups.A linear regression model controlling for maternal and gestational age, diagnosis of gestational or pregestational diabetes, birth weight, gravidity, parity, nulliparity, placental location and AFI was not significantly correlated to the absolute or actual weight differences. In pregnancies with suspected LGA, higher birth weight was an independent and significant predictor of high weight difference inaccuracy. Conclusions: The ultrasonographic EFW 1–3 days before delivery is highly correlated with birth weight, reaffirming the clinical use of abdominal circumference and femur length in estimating fetal weight near labor at term. In pregnancies with suspected LGA fetuses and higher prevalence of macrosomia, ultrasound has higher sensitivity but lower specificity than the controls.

Aims: We aimed to establish a cut-off for short term variation (STV) in msec in electronic FHR tracings as a single parameter for the prediction of neonatal acidemia and hypercarbia at birth. Methods: 195 consecutive cases of singleton pregnancies between 26 to 42 weeks' gestation delivered by cesarean section, with an antepartum tracing performed within 4 hours from birth and umbilical artery gas analysis (UBGA) available at birth. Results: A positive correlation (r = 0.27, p < 0.0001) was found when STV was regressed against gestational age. We also found significant correlations between STV and UBGA parameters (pH [r = 0.12, p < 0.05] and pCO 2 [r =– 0.17, p < 0.01]). In order to evaluate the influence of gestational age on STV values, we subdivided patients into three subgroups (< 34 weeks: n = 31; 35-37 weeks: n = 37, and > 37 wks: n = 127). Only in the subgroup < 34 wks,STV < 5.1 msec was a significant predictor of acidemia (pH < 7.0), (sensitivity: 100%, specificity: 61%, p < 0.05); in the same subgroup STV < 4.9 msec predicted pCO2>60 mmHg with a sensitivity: 71.4% and a specificity: 62.5% (p < 0.02). Conclusion: In cases < 34 weeks' gestation, STV values below 4.9 msec and 5.1 msec are able to predict umbilical artery pH < 7.0 and PCO 2 >60 mmHg, respectively.

The purpose of this paper was to describe whether there are some relationships between amikacin serum levels and central conduction time in brainstem auditory evoked potentials (BAEP) within therapeutic range levels in newborns as index of drug toxicity in brainstem auditory centers in neonatally exposed infants. We performed a cross-sectional study to compare BAEP from 35 infants under amikacin administration and 24 control infants; both examinations were blinded to investigators. Bivariate and partial correlations were calculated between amikacin and BAEP measurements in treated infants. Amikacin determinations were within therapeutic levels.No clinical alterations in BAEP were found and no differences between amikacin-treated and control infants were found. Significant positive Pearson correlation between latency of I-III interwaves interval and amikacin Cmin serum levels was found and was present when calculations were controlled by partial correlations for gestational age at birth and Apgar score at 5 min.The findings suggest that increased amikacin levels in newborns are related to increased latencies in I-III interwave interval in infants, which may be an early index of brainstem effects of subclinical neurotoxicity of amikacin.

Aims: Main objectives were 1) to determine the incidence of higher multiple births from 1995 to 1998 in Switzerland, and 2) to evaluate neonatal mortality and morbidity. Secondary objectives were 3) to compare the results with those of matched singletons, and 4) to compare the present data to the first Swiss study (1985-1988). Methods: Retrospective analysis of maternal and neonatal data obtained from all Swiss hospitals. Results: The incidence of triplet births was 1/3247 and that of quadruplet births 1/81186.The median gestational age was 32 5/7 weeks for triplets, and 28 6/7 weeks for quadruplets. The median birth weight was 1665 g for triplets and 1076 g for quadruplets. Perinatal mortality was 6% for triplets and 19% for quadruplets. Respiratory distress syndrome was the major morbidity as diagnosed in 52% of triplets and 81% of quadruplets. A comparison of triplets with matched singletons showed no significant differences in morbidity and mortality. Compared with the first Swiss study, the mortality rate decreased, while the incidence of triplets increased but decreased for quadruplets. Conclusion: The incidence of higher-order multiple births in Switzerland dropped for quadruplets in the last decade but has increased for triplets. The mortality and morbidity of triplets is comparable to that of singletons with a similar gestational age.

Aims: Intrauterine exposure to tobacco smoke products has been associated with longterm neurobehavioral effects. Modified appetite control might explain the recently observed association between maternal smoking during pregnancy and obesity in offspring. Methods: Some 10,557 British adults aged 42 years born between 3-9 March 1958 were followed up in a birth cohort study (NCDS). The main outcome measure was selfreported poor appetite at age 42 years and main exposure was maternal smoking during pregnancy. Results: The proportion of offspring with poor appetite increased with maternal smoking during pregnancy:nonsmoking 4.5%; (4.0%-5.0%), medium smoking 5.6%; (4.5%-6.8%), variable smoking 6.8%; (4.9%-9.1%) and heavy smoking 7.7%; (6.3%-9.4%). The unadjusted odds ratios for maternal smoking during pregnancy (ever/never) and poor appetite is 1.49 (1.25-1.77) and after adjustment for BMI at 42 years and other potential confounding factors it is 1.22 (1.01-1.48). Conclusions: Offspring of mothers who smoked during pregnancy were more likely to report a poor appetite independent of a number of potential confounding factors. Although not in the expected direction, the results suggest maternal smoking during pregnancy may influence appetite perception through a developmental influence or through confounding by social factors.

Thrombolytic therapy has gained popularity as an alternative to surgery in the treatment of prosthetic heart valve thrombosis.We report on the sequential use of streptokinase followed by recombinant tissue type plasminogen activator (rt-PA) for the treatment of a thrombosed prosthetic mitral valve in a pregnant woman at 26 weeks of gestation. Although thrombolysis was unsuccessful, the patient carried till 34 weeks of gestation and delivered by cesarean section a live newborn with an uneventful postpartum course. Based on our case and on what has been previously described in the literature, thrombolytic therapy should be considered as an option in the management of hemodynamically unstable pregnant patients with prosthetic valve thrombosis.When a single agent proves insufficient, combination therapy should be considered as it might provide hemodynamic stability and improvement in cardiac function that would allow patients at a high surgical risk to carry their pregnancy to viability.

Congenital intracranial tumors are rare and only account for 0.5 to 1.5% of all pediatric brain tumors. Teratoma is the most frequently encountered intracranial tumor at birth. Cephalomegaly and hydrocephalus are the usual clinical presentations. Advances in imaging techniques have improved diagnostic accuracy in congenital brain tumors. But the prognosis of a massive intracranial teratoma is always dismal. We report a congenital mixed malignant germ cell tumor in a male fetus at 27 weeks of gestation, with massive involvement of cerebrum and orbit. According to histological and immunohistochemical studies, the tumor was made up of predominantly immature teratoma combined with a yolk sac tumor. To our knowledge, such a combination has not been well documented in the literature.

Since 1990 avoidance of methylene blue as a dye in diagnostic amniocentesis is recommended. This is the result of the observation that a high incidence of jejunoileal atresia appeared in twin pregnancies following intraamniotic injection of methylene blue.We report a case of jejunal atresia in twins after injection of toluidine blue.We describe the clinical course, discuss possible teratogenic mechanisms and emphasize that no synthetic dyes should be used in second trimester amniocentesis.