Volume 37, Issue 1

This Protocol for Evaluating the Fetal and Neonatal Heart details the indications, views, and measurements to be obtained for both (1) the basic screening examination of the fetal heart (a necessary component of all complete fetal anatomy evaluations) and the specialty study called (2) echocardiography as applied to either the fetus or neonate, using 2D and Doppler ultrasound. While the purpose of the screening study is to detect or exclude the possibility of a cardiac abnormality, echocardiography attempts to diagnose the specific anatomic and physiologic disruption. Also emphasized is the value of a collaborative team approach to management of the fetus and its parents when a cardiovascular anomaly is present, in an effort to achieve a smoother transition from fetus to neonate across the continuum of perinatal care.

In a risk/benefit analysis, currently the use of PAs used in women with a previous history of PTB appears to be worthwhile though the impact on the PTB rate may be minor since 80–90% of women who deliver preterm have no past history. PTB is a heterogeneous condition. With the exception of extremes of gestational age, PTB is due in equal parts to SPTL, preterm prelabour rupture of the membranes (PPROM) and elective PTB for fetomaternal indications. The assessment of the use of PAs to prevent PTB should only relate to previous and subsequent SPTL and not to PTB due to fetomaternal indications.

Objective: To evaluate the accuracy of high cytomegalovirus (CMV) specific IgG avidity in excluding recent infection in patients with anti-CMV IgM antibodies detected during the first trimester, using amniotic fluid obtained by standard amniocentesis. Methods: Records of all patients with a positive anti-CMV IgM with IgG avidity >65% detected during pregnancy were reviewed. Amniocentesis for CMV assessment was offered to all patients. The presence of the virus in amniotic fluid was determined by polymerase chain reaction (PCR) and shell vial testing. Results: Seventy-nine patients with a positive CMV IgM-high IgG avidity combination were identified. The serological tests were performed during the first trimester in 65 (82.3%) patients, of which 28 consented and underwent amniocentesis. All amniotic fluid samples were negative for CMV-PCR and CMV shell vial testing. Conclusions: IgG avidity above 65% is a good indicator of past infection, and thus excludes CMV in the amniotic fluid. In such circumstances, invasive prenatal diagnosis may eventually not be required. This optimistic conclusion, however, needs to be confirmed by large scale studies.

Our aim was to evaluate red blood cell (RBC) changes in normal and preeclamptic cases, and to assess the relationship between maternal and umbilical cord blood (UCB) changes. We evaluated markers of RBC damage: membrane bound hemoglobin (MBH) and band 3 profile – high molecular weight aggregates (HMWSAg), monomer and proteolytic fragments. RBCs are marked for removal by a rise in MBH and in HMWAg. Preeclamptic mothers had significantly higher MBH, RBC count, hemoglobin, hematocrit, reticulocytes and reticulocyte production index (RPI). In UCB from newborns of preeclamptic mothers, we found similar HMWAg, RBC count, hemoglobin and hematocrit; significantly higher MBH, mean cell hemoglobin concentration, mean cell volume, RPI and reticulocyte count. Maternal MBH and HMWAg values were positively and significantly correlated with MBH and HMWAg values in UCB, in normal as well as in preeclamptic pregnancies; in preeclampsia, a significant positive correlation between UCB and maternal bilirubin, and between RPI and proteinuria were found. We conclude that markers of RBC damage/production are altered in preeclampsia, in both UCB and maternal circulation. Our data show similarities between UCB and maternal RBC changes, as suggested by the correlations of markers of RBC damage.

Aims: During term parturition a constant elevation of intercellular adhesion molecule (ICAM-1) as well as increases of endothelial leukocyte adhesion molecule (ELAM-1) and vascular cell adhesion molecule (VCAM-1) in the lower uterine segment and of ICAM-1 in fetal membranes were observed. We examined ELAM-1, ICAM-1 and VCAM-1 during normal term parturition to find out whether amniotic fluid adhesion molecules change accordingly. Methods: Amniotic fluid specimens of 35 patients undergoing cesarean section at term with various stages of cervical dilatation (<2 cm, n=11; 2–<4 cm, n=10; 4–6 cm, n=6; >6 cm, n=8) and different durations of labor (0 h, n=11; >0 h, n=24) were examined for ELAM-1, ICAM-1 and VCAM-1 by enzyme immunoassay. For statistical analysis one-way ANOVA (cervical dilatation) and unpaired t -test (duration of labor) were used (P<0.05). Results: Neither ELAM-1 nor VCAM-1 correlated with cervical dilatation or with the duration of labor. ICAM-1 showed a tendency to decline with the last phase of cervical dilatation (P=0.06) and a significant decline with labor (P=0.046). Conclusions: In contrast to adhesion molecules in the lower uterine segment amniotic fluid adhesion molecules ELAM-1 and VCAM-1 do not rise significantly during parturition. The decline of ICAM-1 may be due to a transfer to other compartments (i.e., lower uterine segment or retroplacental blood) thereby contributing to labor and cervical dilatation.

Objectives: We investigated the correlation between pregnancy-related hormones and serum adenosine deaminase (indicator of cellular immunity) level in women with hyperemesis gravidarum. Materials and methods: Twenty patients with hyperemesis gravidarum and 20 normal pregnancies were included in this prospective, case-control study. Serum adenosine deaminase levels, hematological parameters (white blood cells, neutrophil, monocyte and lymphocyte counts) and hormone levels (prolactin, progesterone, thyroid stimulating hormone, human chorionic gonadotropin β subunit, estradiol (E2)) were measured in all women. Interrelations of blood cell counts and hormone levels with serum adenosine deaminase levels were also investigated. Results : Serum adenosine deaminase, human chorionic gonadotropin β subunit, thyroid stimulating hormone, E2, progesterone and prolactin levels, and lymphocyte and monocyte counts in women with hyperemesis gravidarum were significantly higher than in controls but white blood cells, neutrophil, T3 and T4 levels were not different. Serum adenosine deaminase level correlated with E2, progesterone, lymphocyte, and monocyte levels for all patients. Conclusion: Elevated serum adenosine deaminase in patients with hyperemesis gravidarum may relate to high levels of E2 and progesterone.

Aims: The aims of this study were to assess whether the Msp I polymorphism of von Willebrand factor (vWF) intron 19 gene differs between patients with preeclampsia and normal pregnancies in Chinese Han population, and to study the relationship between the Msp I polymorphism in the vWF intron 19 gene and severity of preeclampsia symptoms within the preeclampsia group. Methods: In this case-control study, peripheral blood samples of 70 patients with preeclampsia and 82 normal pregnancies were genotyped for the Msp I polymorphism in vWF intron 19 gene on the basis of a hospital-based study. The genotyping was performed using polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) and direct sequencing techniques. Results: The genotype frequencies for M+/M+, M+/M− and M−/M− were 22.9, 45.7 and 31.4% in patients with preeclampsia, and 1.2, 36.6 and 62.2% in normal pregnancies, respectively. The frequency of the M+ allele in patients with preeclampsia was significantly higher than in normal pregnancies (45.7 vs. 19.5%). Conclusions: The Msp I polymorphism in intron 19 (M+ allele) of vWF gene is associated with the development and the severity of preeclampsia, and may be a susceptibility factor for preeclampsia.

Objective : To assess the perinatal outcomes of the first three years under the 2004 Italian reproductive legislation obligating transfer of all embryos resulting from insemination of ≤3 oocytes. Study design : We compared the perinatal results of clinical assisted reproductive technology (ART) pregnancies during the three years following the new Italian legislation with the previous three years. Results : There were 583 and 571 clinical pregnancies during the respective periods. Before the law, the overall embryonic and fetal loss rates were significantly higher resulting in a significantly lower rate of live born infants and significantly fewer clinical pregnancies with at least one live born infant. Quadruplet and quintuplet pregnancies were entirely eliminated following the 2004 law but the neonatal mortality rate was not different between the two study periods. Conclusion : The 2004 Italian infertility legislation led to improved quantitative and qualitative outcomes of ART.

Aim: The association between the growth deficit and the occurrence of adverse outcome was analyzed in a cohort of small-for-gestational age fetuses delivered at term. Methods: A cohort of consecutive singleton fetuses suspected of being SGA during the late third trimester and delivered beyond 37 weeks was selected. Growth deficit area was calculated as that between the individual 10 th centile curve of the customized optimal fetal weight and the individual fetal growth curve. Results: A total of 55 women were included. Of these, 16 had 28 adverse events: eight cases of umbilical artery pH<7.15, 9 cases of caesarean section for fetal distress and 11 cases of admission to neonatal intensive care unit. Whereas the mean area of growth deficit was 8.8 kg×week units (SD 7.6) for cases with normal outcomes, it was 13.9 (SD 8.04) for cases with adverse outcomes (P=0.03). A growth area deficit >10 units, predicted the occurrence of adverse outcome with a sensitivity and specificity of 62% and 68%, respectively. Conclusion: In term growth restricted fetuses the degree of growth deficit from the optimal customized growth may be used to identify a subgroup of fetuses at high-risk for adverse outcomes.

Objectives : The onset of preterm labor has been proposed to have survival value and to be adaptive in nature. This hypothesis would predict that induced preterm birth may be associated with higher rates of complications than spontaneous preterm birth. The purpose of this study was to determine if there is a difference in the frequency of neonatal respiratory distress syndrome (RDS), the most common neonatal complication, according to the etiology of preterm birth (e.g., preterm labor [PTL], preterm PROM, or pregnancies which ended because of maternal-fetal indications). Study design : The relationship between the occurrence of RDS and the obstetrical circumstances leading to preterm birth was examined in 257 consecutive singleton preterm births (gestational age: 24–32 weeks). Cases with major congenital anomalies were excluded. The study population was divided into two groups according to the cause of preterm birth: 1) preterm birth due to PTL with intact membranes or preterm PROM (spontaneous preterm birth group); and 2) preterm birth due to maternal or fetal indications (indicated preterm birth group). Results : 1) RDS was diagnosed in 47% of cases; 2) RDS was more common in patients with indicated preterm birth than in those with spontaneous preterm birth group (58.1% vs. 38.4%, P=0.002); 3) Patients with indicated preterm birth had a significantly higher mean gestational age at birth, but lower mean birth weight, lower rate of histological chorioamnionitis and higher rates of cesarean delivery, 5 min Apgar score of <7, and umbilical arterial blood pH of <7.15 than those with spontaneous preterm birth (P<0.05 for each); 4) Antenatal corticosteroids were used in 73.4% of cases with indicated preterm birth and in 76.9% of those with spontaneous preterm birth; 5) Multivariate analysis demonstrated that indicated preterm birth was associated with an increased risk of RDS after adjusting for confounding variables (OR=2.29, 95% CI 1.22–4.29). Conclusions : 1) The rate of RDS is greater following “indicated” rather than spontaneous preterm birth; 2) This observation supports the view that spontaneous preterm labor is adaptive in nature.

Objective: We investigated the role of β 1 integrin in acute renal tubular injury caused by intrauterine asphyxia of neonatal rabbits by exploring the distribution and expression changes in β 1 integrin and its mRNA in renal tubular epithelial cells. Methods: A catheter was used to temporarily block the abdominal aortas of New Zealand pregnant rabbits in order to set up the intrauterine asphyxia animal model. The rabbit pups were randomly divided into control, asphyxia, and calpain inhibitor intervention groups and their renal tubular tissues were examined at 2 h after asphyxia. Immunofluorescence and in situ hybridization were used to examine the expression of β 1 integrin and its mRNA, respectively. Western blot analysis was used to show the proteolysis of β 1 integrin. Calpain inhibitor I was used to show the protective effect of keeping β 1 integrin from being hydrolyzed after asphyxia. Results: (1) Normally, β 1 integrin was located exclusively at the basal surface of renal tubular epithelial cells. After asphyxia a large amount of β 1 integrin shifted from the basal surface to the cytoplasma and the lateral and apical surfaces and its expression decreased significantly, with simultaneous damage to renal tubular integrity and structure, many exfoliated cells and cell fragments obstructed the tubular lumen. (2) The mRNA of β 1 integrin was mainly expressed in the cytoplasma. After asphyxia its expression increased significantly. (3) Proteolysis of β 1 integrin was evident after asphyxia, but was significantly reduced in the calpain inhibitor intervention group. Calpain inhibitor I prevented the decrease and dislocation of β 1 integrin and protected renal tubular integrity and structure. Conclusion: Intrauterine asphyxia caused proteolysis of β 1 integrin, with reduced expression and depolarized distribution, leading to tubular lumen obstruction and renal tubule destruction. Damage to β 1 integrin and the renal tubule was related to the activation of calpain, and calpain inhibitor curtailed these effects.

Aims: To investigate the association between the presence of liver herniation and perinatal course and outcome of fetal omphalocele. Methods: Cases of fetal omphalocele managed at our hospital between 1990 and 2006 were retrospectively reviewed and grouped according to the location of the liver. Results: Thirty-three fetal omphalocele cases were diagnosed. The chromosomal status of 29 of 33 fetuses was determined. The rate of chromosomal abnormalities in cases with an extracorporeal liver was significantly lower (2/18) than in the intracorporeal group (6/11) (P=0.028). In chromosomally normal cases, four with extracorporeal liver resulted in early neonatal death compared to none with intracorporeal liver. Five of the 21 chromosomally normal fetuses showed an abnormal volume of amniotic fluid. All five cases had extracorporeal liver and two of them resulted in neonatal death. Conclusions: Fetuses with an extracorporeal liver had a lower rate of chromosomal abnormalities than those in the intracorporeal liver group. However, in chromosomally normal cases, it appeared that extracorporeal livers might be associated with more life-threatening anomalies, amniotic fluid volume abnormalities, and a higher rate of mortality than in the group with an intracorporeal liver. Upon diagnosis of fetal omphalocele, a careful search for liver location should be conducted before counseling.

Aims: To evaluate the association between the presence of bacterial pathogens in the amniotic cavity at the time of preterm delivery and neuromotor outcome at two years adjusted age in preterm infants born at ≤33 weeks' gestation. Methods: The cohort included 114 preterm infants, born at 23–33 weeks' gestation to mothers with amniotic cavity cultures taken during cesarean delivery who were subsequently evaluated at 24.0±1.1 months corrected age with the Bayley Scales of Infant Development II and a standardized neurologic examination. Results: A group of 67 infants with negative amniotic cavity cultures was compared to 47 infants with positive amniotic cavity cultures ( Ureaplasma urealyticum (Uu) in 32 cases and other bacteria in 15 cases). Patients with positive amniotic cavity cultures had a significantly higher risk for an adverse psychomotor development index (PDI) score (OR 3.1, CI 1.3–7.1), an abnormal neurologic outcome (OR 4.8, CI 1.7–13.8), and a higher probability for diagnosis of cerebral palsy (OR 4.8, CI 1.4–16.4) at two years compared to patients with negative culture results. Isolation of Uu at birth was associated with a particular adverse outcome of preterm infants. Conclusions: Isolation of pathogens from the amniotic cavity at birth is significantly associated with abnormal PDI and adverse neuromotor outcome in preterm infants, irrespective of gestational age and birthweight.

Aim: To investigate whether end-tidal CO 2 monitoring is useful for more rapid recognition of tracheal vs. esophageal intubation as compared to standard clinical evaluation in very low birth weight infants during neonatal resuscitation at birth. Patients and methods: Forty infants were prospectively identified. Tracheal tube placement was evaluated either using an end-tidal CO 2 monitor by an investigator not involved in the resuscitation, or by evaluation of clinical parameters by a resuscitation team unaware of the end-tidal CO 2 data. The time taken to detect accurate placement of the tube using capnometory vs. clinical determination of tracheal or esophageal tube placement was compared. Results: A total of 54 intubations was analyzed from 40 neonates. End-tidal CO 2 monitoring correctly identified all 40 tracheal and all 11 esophageal intubations with 100% accuracy. On the other hand, clinical evaluation demonstrated discrepancies in three cases. The mean time in seconds for capnographic determination was significantly faster than clinical determination for both tracheal (7.5±1.3 vs. 17.0±3.4, P<0.01) and esophageal intubation (6.5±0.7 vs. 19.9±1.8, P<0.01). Conclusion: Exhaled CO 2 detection is a sensitive and accurate technique to confirm tracheal tube placement in very low birth weight infants during neonatal resuscitation.

In a twin pregnancy discordant for a chromosomal or structural abnormality, the family is faced with two alternatives: expectant management or selective feticide of the abnormal fetus. Methods of selective feticide differ according to chorionicity due to the presence of intertwin anastomoses in monochorionic placentas. Intracardiac KCl injection is commonly used in dichorionic pregnancies. Here, we describe an alternative method for selective feticide in dichorionic pregnancies by blood aspiration from the fetal heart until cardiac arrest.

Background: Long-term follow-up is urgently needed to decide on the consequences of new therapies. Objective: This study assesses the use of a national child development screening program for a follow-up examination of a defined patient group. Patients and methods: Neurodevelopmental outcome of 139 survivors after intrauterine laser coagulation for severe twin-twin transfusion syndrome was investigated both according to a standardized neurodevelopmental follow-up and according to the pediatricians' screening examinations. Results: Screening and standardized tests revealed identical results in 90.6% of the cases. Using the national screening program only four out of 139 children (2.9%) with minor neurological disabilities would have been missed. For identifying mild or severe neurodevelopmental abnormalities the screening has a sensivity of 78% and a specifity of 93%. The positive predictive value is 61% and the negative predictive value 97%. Conclusions: The use of already available and established follow-up programs for extended follow-up studies would considerably reduce costs, time and manpower.

No Abstract available

No Abstract available

No Abstract available