Outcome of infants from mothers with anti-SSA/Ro antibodies.

OBJECTIVE: To evaluate the incidence of electrocardiographic and laboratory abnormalities in neonates born from mothers with connective tissue disease and positive for anti-SSA/Ro antibodies. STUDY DESIGN: Electrocardiogram, blood cell counts, liver and renal function tests prospectively obtained from 51 infants born from anti-SSA/Ro-positive mothers with connective tissue disease were compared with those obtained from 50 control infants born from mothers with anti-extractable nuclear antigen (ENA)-negative connective tissue disease. One infant with congenital complete heart block was excluded from analysis. RESULTS: No infant showed sinus bradycardia. A first-degree atrioventricular block at birth was observed in five study group and no control group infants, P=0.023. Atrioventricular blocks spontaneously reverted or remained stable during the first year of life. Mean corrected QT value of infants born from anti-SSA/Ro-positive mothers was slightly prolonged as compared with the control group (0.404+/-0.03 s vs 0.395+/-0.02 s; P=0.060). CONCLUSIONS: Infants exposed to anti-SSA/Ro antibodies had a significantly higher prevalence of first-degree atrioventricular block. At variance with previous studies, we observed a low frequency of hematologic abnormalities and no cases of hepatobiliary disease.     

Extremely low ventricular rate in a fetus with an isolated non-autoimmune complete congenital heart block. Case report

Congenital complete heart block (CCHB) is an uncommon disorder with an incidence of about 1/20,000 in liveborn infants. It can occur in the setting of structurally normal heart or with structural disease; it is associated with high mortality and morbidity and requires a high index of suspicion for early diagnosis and therapy. Isolated CCHB in a fetus is usually associated with the presence of autoantibodies to SSA (Ro) and SSB (La) antigens in the maternal circulation. Such antibodies cross into the fetal circulation and cause inflammation of the conduction tissues; the causal mechanism is not known. Although the prognosis for the majority of fetuses is good, it is less favourable in fetuses with a ventricular rate <55 bpm in early pregnancy or with a decrease in the ventricular rate by >5 bpm during pregnancy. It is not known if the same prognostic criteria apply for fetuses with isolated non-autoimmune CCHB. This article reports authors' experience in managing a pregnancy with an extremely low fetal heart rate (47 bpm) in a single fetus with an isolated non-autoimmune CCHB in which the outcome was favorable.     

Perinatal outcome of twin pregnancies with one structurally affected fetus: a case-control study.

OBJECTIVE: To determine whether one structurally affected fetus of a twin pregnancy further increases the risk of preterm delivery and to compare perinatal morbidity and mortality in these pregnancies with twin gestations with structurally normal fetuses. STUDY DESIGN: The cases (n = 25) included all twin gestations diagnosed from 1991 to 1994 with a sonographically detected fetal anomaly and a structurally normal co-twin delivered after 24 completed weeks' gestation. The control group consisted of 547 twin gestations delivered during the study period with no sonographically detected structural anomalies in either twin. RESULTS: Compared with controls, pregnancies with a single anomalous fetus (cases) delivered at a significantly lower gestational age (mean +/- SD: 34.0 +/- 3.2 weeks versus 35.6 +/- 3.2 weeks; p = 0.019) and had a significantly increased preterm delivery rate (76.0% vs 55.4%; p = 0.042). There was no significant difference in the incidence of intraventricular hemorrhage or respiratory distress syndrome, yet the perinatal mortality (80.0/1000 vs 6.4/1000; p = 0.000) and the average nursery stay (45.5 +/- 43.3 days versus 17.0 +/- 24.0 days; p = 0.003) were significantly increased for cases compared with controls. In addition, a significantly greater birth weight discordancy (> or = 30%) was seen in cases compared with controls (32.0% versus 9.1%; p = 0.002). The normal co-twin did not show any significant difference in the perinatal outcome variables studied when compared with controls. CONCLUSION: Compared with structurally normal twin pairs, twin gestations with a single anomalous fetus are at a significantly increased risk for preterm delivery. In addition, the anomalous fetus, but not the structurally normal co-twin, has a significantly increased mortality rate and a longer nursery stay. Finally, despite the increased risk for preterm delivery in twin pregnancies with one anomalous fetus, it is the nature of the anomaly itself that dictates the perinatal outcome.     

Successful perinatal management of a very low birthweight infant with congenital complete atrioventricular block

We report a very low birthweight infant with congenital complete atrioventricular block (CCAVB) who underwent delayed implantation of a permanent pacemaker without temporary pacing. The female infant was born at 30 weeks gestation and weighed 1422 g. After birth, the infant showed respiratory failure due to pleural effusion and respiratory distress syndrome at birth. The heart rate ranged between 50 and 55 bpm. The chest x-ray demonstrated dilated heart, but echocardiogram showed good systolic ventricular function. Respiratory failure was resolved after supportive treatment without temporary pacing. Mild heart failure due to low heart rate persisted, but was successfully managed by conventional heart failure therapy combined with nasal continuous positive airway pressure. She achieved a body weight gain to 1856 g at the age of 49 days and underwent implantation of a permanent pacemaker. We conclude that it is important to determine the timing of both delivery and pacemaker implantation for successful perinatal management of infants with CCAVB.     

Maternal septicemia with Listeria monocytogenes in second trimester without infection of the fetus.

Two cases of septicemia with Listeria monocytogenes in two pregnant women at the 20th and 23rd weeks of pregnancy, respectively, are presented. The women had delays of 8 and 10 days from onset of symptoms to diagnosis and adequate treatment. Outcome was favorable; both women delivered healthy infants at term.     

Perinatal outcome in women with severe chronic hypertension during the second half of pregnancy.

OBJECTIVES: To determine the perinatal outcome associated with severe chronic hypertension (SCH) in pregnancies of > or =20 weeks' gestation. METHODS: A retrospective analysis of data obtained prospectively of patients with SCH (> or =160/110 mmHg) who were hospitalized and delivered during a 5-year period. Each patient received intensive monitoring of the clinical status throughout the hospitalization (mother, fetus and neonates). Antihypertensive drugs were used for blood pressure > or =160/110 mmHg, glucocorticoids for pregnancies of 24-34 weeks and magnesium sulfate for women with superimposed pre-eclampsia (SPE). The main outcome measures were fetal and neonatal deaths, fetal growth restriction (FGR), major neonatal complications and length of stay in the neonatal intensive care unit (NICU). RESULTS: Of 154 women studied, 78% developed SPE and the mean week's gestation at delivery was 34.5+/-4.6. The average birth weight was 2329+/-1011 g. and the FGR was 18.5%. Four patients had a dead fetus at the time of admission, eight during the hospitalization and there were six neonatal deaths resulting in perinatal mortality of 11.4%. Thirty-eight babies were admitted to the NICU, average stay was 14.8 days. The most common contributors to neonatal mortality and morbidity were pulmonary complications and sepsis. CONCLUSIONS: This study found that the neonatal outcomes in pregnancy with SCH are better than the historical experience, but preterm deliveries, cesarean section, SPE, abruptions and total perinatal mortality remains very high.     

Increased level of second trimester maternal serum chorionic gonadotropin in pregnancy with a fetus affected by homozygous alpha-thalassemia 1

With enzyme immunoassay, maternal serum chorionic gonadotropin (MShCG) level was determined in 58 pregnancies affected with fetal homozygous alpha-thalassemia 1. In 40 pregnancies with a gestational age of 10 to 14 weeks, 8 (20%) had an MShCG level above 2.5 multiples of the median (MoM); while in the other 18 pregnancies with a gestational age of 15 to 23 weeks, 14 (78%) had a level above 2.5 MoMs and none had a level below the median. Homozygous alpha-thalassemia 1 of the fetus was associated with an elevated MShCG. Therefore in second-trimester screening for Down's syndrome by measurement of MShCG, homozygous alpha-thalassemia 1 should also be considered if elevated MShCG levels are found. Received: 15 December 1993 / Accepted: 6 April 1994     

Respiratory outcome in preterm small for gestational age fetuses with or without abnormal umbilical artery Doppler and/or maternal hypertension

Objective.?To study respiratory outcome in preterm small for gestational age (SGA) fetuses with or without signs of intrauterine growth restriction due to placental insufficiency, and with or without maternal hypertension.

Methods.?This was a retrospective study of 187 neonates with birth weight <10^th percentile and gestational age <34 weeks. Results from umbilical artery Doppler velocimetry were used to identify the abnormal Doppler subgroup.

Results.?No significant difference in respiratory outcome between SGA fetuses with normal (SGA-N) or abnormal (SGA-A) umbilical artery Doppler examination was found. Within the SGA-A group, the respiratory distress syndrome (RDS) incidence (OR 5.6, 95% CI 1.7–18.3), RDS grade (OR 6.7, 95% CI 1.2–38.5), and need for surfactant (OR 5.3, 95% CI 1.1–24.4) were higher in infants of women with hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome as compared to those of normotensive mothers.

Conclusions.?Lung maturation is not accelerated with placental insufficiency. SGA-A fetuses of mothers with HELLP syndrome have a significantly poorer respiratory outcome than those with healthy mothers. Possibly, fetuses of mothers with HELLP syndrome are subjected to ‘oxidative stress’ causing lung damage rather than lung maturation.     

Treatment of fetal congenital complete heart block with maternal administration of beta-sympathomimetics (terbutaline): a case report

We report a case of fetal congenital heart block treated with maternal administration of beta-sympathomimetics. The case was diagnosed as fetal complete heart block associated with maternal anti-Ro/SS-A antibody at 22 weeks of gestation. By fetal sonography, the ventricular rate was revealed to be 60 beats/min and mild cardiomegaly was shown. We initiated maternal administration of a sympathomimetic, specifically terbutaline, to prevent fetal heart failure. An increase in the fetal ventricular rate and an improvement in cardiac function were both achieved during the treatment. A viable infant was delivered by an elective cesarean section without complications at term. Maternal administration of the beta-adrenergic agent terbutaline is suggested to be effective for improving fetal congenital heart block in order to prevent heart failure in utero.     

Comparison of pregnancy outcome among nulliparas with and without microalbuminuria at the end of the second trimester

Objective

To evaluate the rate of poor pregnancy outcome among nulliparas who had microalbuminuria at the end of the second trimester of their pregnancy.

Methods

A prospective cohort study was performed on 490 nulliparous women who were at the end of the second trimester of pregnancy. Urine tests for albuminuria and creatinine measurements were performed in all women and the albumin to creatinine ratio (ACR) was calculated. The women with microalbuminuria (exposed group) and those without microalbuminuria (nonexposed group) were monitored until the end of their pregnancy and compared for pregnancy outcome.

Results

Preterm labor (57.9% versus 13.5%), preeclampsia (50.0% versus 8.6%), intrauterine growth restriction (42.1% versus 6.4%), and preterm premature rupture of membranes (31.6% versus 10.2%) were significantly more common in the exposed group. The rates of gestational diabetes did not differ significantly between the 2 groups. In multivariate logistic regression analyses, microalbuminuria increased the risks for preterm labor (adjusted OR 2.4; 95% CI 1.1-5.5, P = 0.03) and preeclampsia (adjusted OR 9.5; 95% CI 4.6-19.3, P < 0.001).

Conclusion

Microalbuminuria at the end of the second trimester of pregnancy might increase the risks of preterm labor, preeclampsia, intrauterine growth restriction, and preterm premature rupture of membranes.     

Respiratory outcome in preterm small for gestational age fetuses with or without abnormal umbilical artery Doppler and/or maternal hypertension.

OBJECTIVE: To study respiratory outcome in preterm small for gestational age (SGA) fetuses with or without signs of intrauterine growth restriction due to placental insufficiency, and with or without maternal hypertension. METHODS: This was a retrospective study of 187 neonates with birth weight <10(th) percentile and gestational age <34 weeks. Results from umbilical artery Doppler velocimetry were used to identify the abnormal Doppler subgroup. RESULTS: No significant difference in respiratory outcome between SGA fetuses with normal (SGA-N) or abnormal (SGA-A) umbilical artery Doppler examination was found. Within the SGA-A group, the respiratory distress syndrome (RDS) incidence (OR 5.6, 95% CI 1.7-18.3), RDS grade (OR 6.7, 95% CI 1.2-38.5), and need for surfactant (OR 5.3, 95% CI 1.1-24.4) were higher in infants of women with hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome as compared to those of normotensive mothers. CONCLUSIONS: Lung maturation is not accelerated with placental insufficiency. SGA-A fetuses of mothers with HELLP syndrome have a significantly poorer respiratory outcome than those with healthy mothers. Possibly, fetuses of mothers with HELLP syndrome are subjected to 'oxidative stress' causing lung damage rather than lung maturation.     

Perinatal magnetic resonance fetal lung volumetry and fetal lung-to-liver signal intensity ratio for predicting short outcome in isolated congenital diaphragmatic hernia and cystic adenomatoid malformation of the lung

AIM: To evaluate the usefulness of magnetic resonance imaging (MRI) in predicting the risk of lethal pulmonary hypoplasia in fetuses. METHODS: The subjects consisted of 15 fetuses (29-40 weeks' gestation), including fetuses with major malformation diagnosed on prenatal ultrasonography. MRI using a 1.5 T magnet and half-Fourier acquisition single-shot fast spin-echo sequences were applied to all fetuses at 29-36 weeks. Fetal lung-to-liver signal intensity ratio (LLSIR) was calculated by medians of region-of-interest analysis; estimated fetal bodyweight (FBW), by ultrasonography; and estimated fetal lung volume (FLV), by planimetric measurement of total lung volume. FLV/FBW was also calculated. The presence of the pulmonary hypoplasia in neonates was identified based on clinical and anatomico-pathological findings. Differences in LLSIR and FLV/FBW were analyzed for surviving and non-surviving neonates. RESULTS: Ten surviving neonates had a median LLSIR of 3.00, range: 1.60-4.40, while that in seven non-surviving neonates was 2.21, range: 0.70-3.72; no significant difference was found between the groups. Surviving neonates had a median FLV/FBW of 11.4, range: 7.1-15.7, while that in non-surviving neonates was 4.4, range: 3.1-5.7. FLV/FBW in non-surviving neonates was significantly lower than that of the FLV/FBW for surviving fetuses (P<0.05). CONCLUSIONS: Low FLV/FBW may be useful in prenatally predicting mortality in fetuses with pulmonary hypoplasia.     

Heart rate variability as an indicator of outcome in congenital diaphragmatic hernia with and without ECMO support.

OBJECTIVE: To examine differences in the spectral power content in neonates diagnosed with congenital diaphragmatic hernia (CDH) who survive or succumb. STUDY DESIGN: A case-series study design evaluated four neonates diagnosed with CDH, two of which were supported by extracorporeal membrane oxygenation (ECMO). The electrocardiogram signal was digitized at 1000 Hz and the Lomb periodogram was computed for the series of interbeat intervals. RESULTS: Neonates with CDH who survived had log total power values greater than 2. Those with CDH who did not survive had log total power less than 2, but generally exceeded 3 while they were supported by ECMO. CONCLUSIONS: Neonates who consistently displayed increasing total spectral energies had a better outcome than those whose spectral energies were low. Subjects who succumbed expressed the lowest values, suggesting that a frequency-based evaluation of HRV may be a sensitive prognosticator of outcome that requires further investigation.     

Perinatal outcome with HELLP/partial HELLP complicating hypertensive disorders of pregnancy. An Indian rural experience.

A total of 615 women with hypertensive disorders during pregnancy were the study subjects. Of these, 145 (23.58%) women had HELLP or partial HELLP (only one or two of the three components H,EL, LP). Overall, eight (1.3%), i.e. five out of 399 primigravida (1.2%) and three of the 216 multigravida (1.3%), had complete HELLP and the remaining 137 (22.2%) had partial HELLP. Of the 399 primigravida with hypertensive disorders, 107 (26.5%) had partial HELLP, statistically significantly more (p<0.002) than the 30 out of the 216 (13.8%) multigravida. In 210 (44.6%) out of 470 women with hypertension without HELLP/partial HELLP, labour was induced and the perinatal mortality rate (PMR) was 138.9 (58.06 in term and 363.63 in pre-term cases), and in the other 260 women in whom labour was not induced, PMR was 96.15 (in term cases 74.07 and in pre-term 120). Among the women with HELLP/partial HELLP (145), out of the 64 women in whom labour was induced, the PMR was 359.37 (235.29 in term and 500 in pre-term) and of those in whom labour was not induced (81), PMR was 209.87 (106 in term cases and 352.94 in pre-term). All the eight women with the full HELLP syndrome had labour induced, the PMR in these cases was 500. Overall, in women with HELLP/partial HELLP, the PMR was 275.8 and in the remainder with hypertensive disorders without HELLP/partial HELLP, it was 114.89.     

Hyperuricemia facilitates the prediction of maternal and perinatal adverse outcome in patients with severe/superimposed preeclampsia

Objective.?Hyperuricemia has received much attention and debate recently with regard to its utility as a marker for preeclampsia and as a predictor of adverse maternal–fetal outcome. This investigation was undertaken in patients with severe/superimposed preeclampsia to determine whether the maternal uric acid (UA) level at initial hospital admission is a useful predictor of subsequent adverse maternal and/or perinatal outcomes.

Methods.?Retrospective analysis of all patients diagnosed with severe preeclampsia, superimposed preeclampsia or HELLP syndrome during 2005 at the University of Mississippi Medical Center (UMMC). Clinical and laboratory data were collected, entered and stored electronically in a password protected, secure system.

Results.?Adverse maternal outcomes occurred in 15.3% of 258 patients in the cohort. Mean UA concentration in the absence of adverse maternal outcomes was 342.6?±?77.3 compared to 396.1?±?117.2?μmol/l in pregnancies with complications (p?<?0.001). The positive likelihood ratio (LR) for adverse maternal outcome was 5.3 with UA?≥?76.3 μmol/l and creatinine ≥1.0 mg/dl. LRs rose in association with other abnormal preeclampsia serum markers. Adverse perinatal outcomes occurred in 45.2% of births. The LRs for adverse perinatal outcomes remained unchanged around 1.0. Mean UA was 363.4?±?91.0 compared to 339.0?±?80.9?μmol/l in pregnancies without adverse outcomes (p?=?0.021).

Conclusions.?Maternal hyperuricemia is a better predictor of maternal than perinatal risk and adverse outcome.