Volume 31, Issue 6

The use of ultrasonography (USG) during pregnancy provides a tremendous amount of valuable information about fetal and maternal well-being. However, in some cases the image quality may be poor due to maternal fat tissue, fetal position, or some other reason. Magnetic resonance imaging (MRI) can provide clear images from multiple angles without X-ray exposure. We believe that it is important to evaluate the usefulness of MRI for diagnostic purposes during pregnancy. While MRI can provide different information to what can be obtained from USG, it is not always superior to USG. The clinical indications for MRI during pregnancy are limited but well defined. Fetal MRI is a valuable complement to USG especially in the further evaluation of problems first detected by USG. When MRI is performed, we must consider its purpose and accordingly determine the appropriate procedure to provide the most precise and useful diagnostic information.

Ultrasound is the screening modality of choice for evaluation of the fetal central nervous system (CNS). However, in cases of difficult diagnosis further fetal investigation is desirable. Due to ultrafast magnetic resonance imaging (MRI) techniques artifacts from fetal motions are minimized. MRI involves no exposure to radiation and hence appears to be safe. Due to the better soft tissue contrast, additional investigation by MRI may extend the sonographic diagnosis of fetal CNS-anomalies. Ultrasound and MRI are complementary imaging methods in the evaluation of the fetal CNS. The most important indications for ultrasound are screening for CNS anomalies and serial assessment of the dynamic of the disorder. The most important indications for fetal MRI are the “second opinion” and investigation by fetal MRI instead of postpartum MRI (especially in cases of planned postpartum intervention). In this article the indications and limitations of ultrasound and magnetic resonance imaging in the evaluation of the fetal CNS are discussed.

We aimed to determine the value of maternal erythrocyte malondialdehyde levels in the prediction of preeclampsia. 110 healthy women were included in this prospective study. Maternal erythrocyte malondialdehyde levels were measured at each trimester of pregnancy (10–14, 20–25 and 30–35 gestational weeks). On follow-up, patients were assigned to two groups as normotensive women and preeclamptic patients. Preeclampsia had developed in eight (8.9%) of the 90 pregnant women who completed the study. Preeclamptic patients were diagnosed between 36 and 39 gestational weeks (36.8±1.0 weeks). Malondialdehyde levels of preeclamptic patients increased significantly in the third trimester (p < 0.05), while there was no difference between values of malondialdehyde in the first and second trimester. Malondialdehyde levels were significantly higher in the patients who developed preeclampsia than in those who did not in the third trimester (p < 0.05). With the use of the receiver operating characteristics (ROC) 35.98 nmol malondialdehyde/gm hemoglobin was found to be a cut-off value predictive for the development of preeclampsia in the third trimester. However, cut-off values in the first and second trimesters could not be found. The sensitivity, specificity, positive and negative predictive values were 89, 75, 29 and 98%, respectively. Preeclampsia risk was found to increase nearly 24 times in values above 35.98 nmol malondialdehyde/ gm hemoglobin. Our results showed that maternal erythrocyte malondialdehyde could predict patients within a few weeks prior to onset of clinical symptoms of preeclampsia in the third trimester. There is no evidence of enhanced early lipid peroxidation in pregnancies with late onset preeclampsia.

The aim of this study was to compare glucose transport and utilization in human placentae from pregnancies affected by insulin-treated GDM with and without macrosomia, and from non-diabetic control pregnancies. Placental lobules were perfused for 4 h. Maternal D-glucose concentration was 4, 8, 16, or 24 mM while the fetal D-glucose was maintained at 3mM. Hay WW: Regulation of placental metabolism by glucose supply. Reprod Fertil Dev 7 (1995) 365 C-D-glucose and Combs CA,E Gunderson, JL Kitzmiller, LA Gavin, EK Main: Relationship of fetal macrosomia to maternal postprandial glucose control during pregnancy. Diabetes Care 15 (1992) 1251 H-L-glucose were infused into the maternal circulation. Radioactivity, D-glucose and L-lactate levels were measured in the fetal and maternal effluent perfusates. Glucose uptake from the maternal perfusate, and transfer to the fetal effluent were not significantly different between groups. Insulin-treated GDM group without macrosomia had reduced glucose utilization compared to the control group while the insulin-treated GDM group with macrosomia did not. Lactate release into the fetal effluent was significantly reduced in both insulintreated GDM groups compared to the control group. In conclusion, placental glucose utilization is different between insulin-treated GDM placentae with and without fetal macrosomia.

Aims: To correlate maternal-fetal Doppler velocimetry parameters to indices of fetal lung maturity (FLM). Methods: Fifty-five consecutive third trimester pregnancies in which a pulsed-wave Doppler study, including uterine resistance index (Ut RI), umbilical artery pulsatility index (UA PI), middle cerebral artery pulsatility index (MCA PI) and the UA/MCA ratio was performed within 24 hours before amniocentesis and within a week from birth. FLM was determined by amniotic fluid lamellar bodies count (LBs). Results: A positive correlation between MCA PI and LBs (p < 0.007, r = 0.44) was found. MCA PI showed a trend to lower values in fetuses that developed RDS at birth (1.3±0.5 vs. 1.7±0.4, NS). LBs significantly decreased as Ut RI increased (O.R.: 0.98, C.I. 0.97–0.99, p < 0.05). A mean Ut RI > 0.64 was correlated to delayed FLM (LBs < 20,000/μl; sensitivity: 90.9%, specificity: 90.3%; positive predictive value: 76.9%, negative predictive value: 96.6%). Comment: In third trimester pregnancies abnormal uterine artery waveforms may be associated to a delayed FLM, as expressed by decreased amniotic fluid LBs.

The thrifty phenotype hypothesis proposes that the epidemiological associations between poor fetal and infant growth and the subsequent development of the metabolic syndrome, result from the effects of poor nutrition in early life. The present review however, considers an opposite explanation. We hypothesize that fetal over-nutrition plays a major role in the development of the metabolic syndrome. We found evidence that the thrifty phenotype may be the consequence of fetal hyperglutamatemia. Maternal glutamate (GLU) reaches the fetal circulation, as part of the materno-fetal glutamine-glutamate exchange. Glutamine is absorbed from the maternal circulation, and deaminated for nitrogen utilization, resulting in a fetal production of GLU. GLU is extracted as it returns to the placenta. When the umbilical plasma flow is low, GLU may be trapped in the fetal circulation, and reaches neurotoxic levels. Administering GLU to newborn rodents completely destructs arcuate nucleus neurons, and results in permanently elevated plasma leptin levels that fail to adequately counter-regulate food intake. Chronic fetal exposure to elevated levels of GLU may be caused by chronic maternal over-nutrition or by reduced umbilical plasma flow. We strongly suggest abandoning the flavoring agent monosodium glutamate and reconsidering the recommended daily allowances of protein and amino acids during pregnancy.

Aim: To evaluate the developmental pattern of fetal hand movements and facial activity and expression during the second and third trimester of pregnancy by four-dimensional ultrasound (4D-US). Subjects and methods: A total of 25 fetuses in uncomplicated pregnancies were analyzed; 15 fetuses at 13 to 16 weeks and 10 fetuses at 30 to 33 weeks of gestation were studied with abdominal 4D-US. After standard assessment in two dimensional (2D) real-time B mode, a 4D mode was switched on. Further examination lasted a maximum of 15 minutes. Results: Isolated hand movement and subtypes of hand movements were easily recognized by 4D-US. The subtypes of hand to head movement are: hand to head, hand to mouth, hand near mouth, hand to face, hand near face, hand to eye and hand to ear. All subtypes of hand to head movement can be seen from 13 weeks of gestation, with fluctuating incidence. Facial activities and different forms of expression are easily recognized by 4D-US. Among these, two types can be easily differentiated: smiling and scowling. Conclusions: 4D-US is superior over real-time two-dimensional ultrasound (2D-US) for qualitative, but inferior for quantitative analysis of hand movements. Thus 4D-US makes it possible to determine exactly the direction of the fetal hand, but the exact number of each type of hand movements can still not be determined. 4D-US is superior over two- and three-dimensional sonography in the evaluation of complex facial activity and expression. Among facial activities observed by 4D-US, simultaneous eyelid and mouthing movements dominate between 30 and 33 weeks of gestation. Pure mouth movements such as mouth opening, tongue expulsion, yawning and pouting are present, but at a significantly lower incidence. Facial expressions such as smiling and scowling can be precisely observed using 4D-US.

Aims: To determine the usefulness of the stable microbubble test (SMT) and of the click test (CT) on gastric aspirates obtained soon after birth to predict respiratory distress syndrome (RDS) in preterm babies not requiring ventilation at birth. Patients and methods: The study was carried out with a cohort between 24 and 34 weeks of gestational age. Gastric secretions were collected before 1 hour of life and frozen for further analysis. Results: 110 neonates were studied. For a cut-off value ≤ 10 microbubbles/mm 2 (mb/mm 2 ) the sensitivity and specificity to predict RDS were 73.9% and 92%, respectively, in the SMT. The best SMT cut-off point to predict RDS was ≤ 15 mb/mm 2 (sensitivity = 82.6%;specificity = 85.1%) if equal weight was given to false-positive and false-negative results. CT (104 samples) showed a sensitivity of 100% and a specificity of 45.1% to predict RDS. The overall accuracy of the SMT was better than the overall accuracy of the CT (87.5% vs. 64.4%; p < 0.001) to predict RDS. Conclusions: The SMT is more accurate than the CT to predict RDS in infants below 35 weeks of gestational age and may be helpful to select patients to receive surfactant.

Two premature infants with very low birth weight were diagnosed with staphylococcal scalded skin syndrome (SSSS) during hospitalization in the neonatal intensive care unit. This syndrome which is rare in premature infants, is characterized by blistering and superficial desquamation of the skin and is caused by two epidermolytic toxins (ETA and ETB) produced by Staphylococcus aureus . Staphylococcal scalded skin syndrome usually occurs in young children probably because of inefficient clearance of the epidermolytic toxins from the bloodstream, which causes dysfunction of cell adhesion in the superficial epidermis. Early diagnosis and early treatment with parenterally administered beta-lactamase resistant penicillins are important to prevent life threatening complications of this syndrome.

Glutathione plays an important role in quenching reactive oxygen species, resulting in oxidation of glutathione, which in times of prolonged oxidative stress may be excreted from the erythrocyte. We investigated arterial and venous umbilical cord levels of glutathione in neonates born by vaginal delivery (n = 140) or cesarean section (n = 38). In a subset of neonates who were delivered vaginally maternal levels were assessed in parallel (n = 14). Median (5 th –95 th percentile) glutathione levels in venous and arterial umbilical samples were higher after vaginal delivery as compared to cesarean section, 2.7 (0.9–7.3) versus 2.0 (0.6–11.5; P < 0.03) and 3.5 (0.6–22.7) versus 2.3 (0.7–24.3) μmol/L (P < 0.02), respectively. Maternal glutathione levels were higher, 7.8 (4.3–10.6) μmol/L, than corresponding venous (P < 0.001) or arterial (P < 0.02) umbilical levels. These results suggest that vaginal delivery is associated with more oxidative stress than delivery by cesarean section.

Upper gastrointestinal contrast studies are frequently performed in neonates to rule out conditions such as malrotation. Low osmolality water-soluble (LOWS) contrast media are currently considered safe for use in neonates. The clinical course of a neonate with suspected necrotising enterocolitis, who deteriorated significantly due to peritonitis following contrast study with LOWS, is reported. The possibility that LOWS contrast media may not always be safe in high-risk neonates is raised.

Thrombocytopenia in pregnancy is a frequent cause of hematological consultation. Autoimmune thrombocytopenic purpura results from platelet destruction due to autoantibodies. Spontaneous intracranial hemorrhage is a rare but devastating complication of these patients. We present a fatal case of intracranial hemorrhage in a 18 week pregnant woman diagnosed with autoimmune thrombocytopenia. The clinical course and treatment of this unusual clinical complication is discussed in relation to the world literature.

A 31-year-old Japanese pregnant woman had no remarkable previous medical and family histories except for artificial abortion in 1993. A full-term normal infant was subsequently delivered in 1998. In this pregnancy, she began to experience general fatigability with a hemoglobin concentration of 8.5 g/dl at 19 weeks of gestation. Although she had been treated with intravenous iron, the hemoglobin decreased to 6.0 g/dl. She was referred to our hospital at 34 weeks of gestation. The laboratory data were as follows on this admission; hemoglobin 5.1 g/dl, RBC 128 × 10 4 /l, reticulocytes 1.1%, WBC 7.1 × 10 9 /l, platelet count 229 × 10 9 /l, folic acid 5.6 ng/ml, serum vitamin B 12 200 pg/ml, ferritin 184 ng/ml, parvovirus B19 (−). A bone marrow aspiration revealed normal granulopoiesis and megakaryocytes, but almost complete absence of erythropoietic precursors. A diagnosis of pure red cell aplasia was made due to these findings. Treatment with prednisone (50 mg/day) and blood transfusion was started before delivery. She was delivered transvaginally at 37 weeks of gestation. The neonate was a normal female infant without anemia (hemoglobin 17.9 g/dl) and the 1 minute Apgar score was 8. Her hemoglobin level rose to 12.1 g/dl spontaneously two weeks after delivery.

Background: Mucopolysaccharidosis type VII (MPS VII) is a rare lysosomal storage disease first described by Sly in 1973. There are fewer than thirty reported cases world wide. This extremely rare disorder can present in-utero as hydrops fetalis and has a high recurrence rate. However, prenatal diagnosis in the absence of a previously affected child, has not been reported to date. Case: This is a case of a non-consanguineous couple, with no history of a previously affected child with MPS VII, presenting with recurrent hydrops fetalis. During the work-up, the affected fetus was diagnosed in-utero with β-glucuronidase deficiency which is pathognomonic for MPS VII. Prenatal diagnosis was then performed in subsequent pregnancies. Conclusion: The importance of an extensive and thorough investigation for the etiology of hydrops fetalis is discussed.

Authors suggest that high incidence of persistence pulmonary hypertension among neonates delivered by elective cesarean is related to lower levels of circulating norepinephrine in neonates after cesarean section than after vaginal delivery.