Diabetic nephropathy: pregnancy performance and fetomaternal outcome

A study of 31 continuing pregnancies complicated by diabetic nephropathy was conducted to determine the effects of diabetes-associated renal disease on maternal health and fetal outcome. Throughout pregnancy there was a significant increase in maternal blood pressure (p less than 0.001) and proteinuria (p less than 0.0001), with nephrotic syndrome (greater than 3.0 gm protein/day) developing in 71% of pregnancies. After birth, however, proteinuria reverted to levels not significantly different from values in early pregnancy. There was no apparent adverse effect of pregnancy on the natural course of the underlying renal disease. Stillbirths occurred in two patients (6%), and the remaining 29 pregnancies resulted in live-births at a mean gestational age of 36 weeks. Seventy percent of these infants were appropriate for gestational age, whereas 16% were small and 13% were large for gestational age. Birth weight was best correlated with gestational age and creatinine clearance (p less than 0.0001). Neonatal complications included respiratory distress syndrome (19%), hyperbilirubinemia (26), and congenital malformations (10%). The uncorrected perinatal survival rate was 94%. These data suggest that with contemporary methods of maternal evaluation and treatment, fetal surveillance, and neonatal care, the risks to patients with diabetic nephropathy during pregnancy are not excessive. The likelihood of a successful fetal and neonatal outcome is comparable to that in other patients with insulin-dependent diabetes.     

Excessive maternal weight and pregnancy outcome.

OBJECTIVES: This study was undertaken to determine the influences of increased maternal prepregnancy weight and increased gestational weight gain on pregnancy outcome. STUDY DESIGN: This was a longitudinal retrospective study of 7407 term pregnancies delivered from 1987 through 1989. After excluding cases with multiple fetuses, stillbirths, fetal anomalies, no prenatal care, selected medical and surgical complications, and those with incomplete medical records, 3191 cases remained for analyses by determination of odds ratios for obstetric outcomes, by chi 2 tests for significant differences and by adjustment for risk factors with stepwise logistic regression. RESULTS: Both increased maternal prepregnancy weight (body mass index) and increased maternal gestational weight gain were associated with increased risks of fetal macrosomia (p less than 0.0001), labor abnormalities (p less than 0.0001), postdatism (p = 0.002), meconium staining (p less than 0.001), and unscheduled cesarean sections (p less than 0.0001). They were also associated with decreased frequencies of low birth weight (p less than 0.001). The magnitude of the last was less than that of the other outcomes. CONCLUSIONS: Increased maternal weight gain in pregnancy results in higher frequencies of fetal macrosomia, which in turn lead to increased rates of cesarean section and other major maternal and fetal complications. Because these costs of increased maternal weight gain appear to outweigh benefits, weight gain recommendations for pregnancy warrant careful review.     

Treatment of fetal anemia due to red-cell alloimmunization with intrauterine transfusions in the Netherlands, 1988-1999

OBJECTIVE: To assess pregnancy outcome after intrauterine transfusion (IUT) for fetal anemia due to red-cell alloimmunization in the Netherlands over 11 years, in order to improve care and counseling. METHODS: A retrospective cohort study was conducted from January 1, 1988, to January 1, 1999. Data were collected prospectively on all red-cell alloimmunized pregnancies requiring intrauterine blood transfusions. Primary outcome variables were fetal and neonatal survival in relation to the type of antibody, gestational age and presence or absence of hydrops. In addition, we studied short-term neonatal morbidity and procedure-related complications. RESULTS: A total of 210 fetuses from 208 pregnancies received 593 transfusions. Overall survival rate was 86%. Survival of hydropic fetuses (78%) was significantly different from those without hydrops (92%). Low survival rates were especially found in hydropic fetuses with the first transfusion at gestational ages of 20 weeks or less (55%) or between 28 and 32 weeks (59%). In maternal rhesus D [Rh(D)] immunization 89% of fetuses survived, whereas survival in the case of Kell immunization was 58%. All fetuses with anemia due to Rh(c) immunization survived. The overall fatal procedure-related complication rate was 1.7% per procedure, resulting in a fetal loss rate of 4.8%. CONCLUSIONS: Intrauterine intravascular transfusions are effective in the management of fetal alloimmune anemia. Fetal hydrops, mostly associated with late referral, decreases the chance of survival. To improve the outcome of red-cell alloimmunized pregnancies early diagnosis of fetal anemia and referral to a specialized center are important, enabling the start of treatment before hydrops develops.     

Fetal breathing movements and prostaglandin levels in pregnancies complicated by premature rupture of the membranes.

We have previously demonstrated that maternal and fetal prostaglandin levels may be elevated in patients with pregnancies complicated by premature and prolonged rupture of the membranes (PPROM) compared to patients with intact membranes. In the fetal lamb, infusion of prostaglandin abolishes fetal breathing movements and in human pregnancies with PPROM and with poor outcome, fetal breathing movements are absent. The aim of this study was to determine fetal breathing activity in pregnancies complicated by PPROM which had elevated prostaglandin levels. One-hour ultrasound examinations were performed on nine fetuses whose mothers had had premature rupture of the membranes at 28 weeks gestation and a median of 4 days prior to the ultrasound examination. The number of fetal breathing movements (FBM) and percentage of time that each fetus spent breathing was documented and this was then related to control values. Following the completion of the ultrasound examination, cordocentesis was performed and blood sent for estimation of bicyclo PGEM levels. All of the fetuses made some breathing activity during the one-hour period, but the number of FBM varied from 1 to 181 (median 21). The percentage time that the fetuses spent breathing was much lower than that which would be expected for their gestational age, being a median of 1.3% (range less than 0.1 to 50.8%) of control values. As bicyclo PGEM levels were elevated in these nine fetuses, these data suggest that reduction in breathing activity in fetuses of pregnancies complicated by PPROM may be due to elevated prostaglandin levels.     

Alterations in vitamin D metabolites and minerals in diabetic pregnancy

Vitamin D metabolites and minerals involved in bone metabolism were studied in 68 control mothers, 14 gestational diabetics and 68 insulin-dependent diabetics during pregnancy and at delivery. 25(OH)D and 1,25(OH)2D concentrations were significantly (p less than 0.001) lower in insulin-dependent diabetics than in the control or gestational diabetic groups. A similar difference was also observed between infants. 24,25(OH)2D, phosphorus and magnesium values were similar in all groups. Corrected calcium values were significantly lower in both mothers (p less than 0.001) and infants (p less than 0.05) in the insulin-dependent group than in the other two groups. Postpartum, 10% of infants of diabetic mothers received calcium therapy. Our results show alterations in vitamin D and mineral metabolism in pregnant insulin-dependent diabetics and their newborn infants and indicate observation during pregnancy and after delivery.     

Elevated maternal glycohemoglobin in early pregnancy and spontaneous abortion among insulin-dependent diabetic women

Insulin-dependent diabetic women without adequate glucose control have a higher rate of spontaneous abortions than does the general population of pregnant women. The present study examined whether insulin-dependent diabetic women who experienced spontaneous abortions had higher levels of glycohemoglobin in the first trimester than did insulin-dependent diabetic women who had normal pregnancy outcomes. Measurement of glycohemoglobin during the first trimester provides an integrated, retrospective index of glucose control during the phase of organogenesis. This study evaluated 116 pregnancies in 75 insulin-dependent diabetic women. Ninety pregnancies progressed beyond 20 weeks, with normal outcome. Twenty-six pregnancies terminated in spontaneous abortions before 20 weeks. The mean gestational ages for sampling of glycohemoglobin for the women who experienced spontaneous abortion and those for the women with pregnancies of more than 20 weeks were not significantly different. The mean level of glycohemoglobin for the women who experienced spontaneous abortions was significantly greater than that for the women with pregnancies of more than 20 weeks (p less than 0.05). Individual levels of glycohemoglobin of less than 12% at 8 to 9 weeks' gestation were associated with favorable outcomes, whereas levels of glycohemoglobin of more than 12% were predictive of a greater incidence of spontaneous abortions (p less than 0.05). These data suggest that the poorly controlled pregnant diabetic patient, as reflected by high levels of glycohemoglobin early in pregnancy, has an increased risk of spontaneous abortion.     

Relation between increased fetal nuchal translucency thickness and chromosomal defects

OBJECTIVE: To examine the prevalence and distribution of all chromosomal defects in fetuses with increased nuchal translucency thickness. METHODS: Assessment of risk for trisomy 21 was carried out by a combination of maternal age and fetal nuchal translucency thickness at 11-13 + 6 weeks. A search of the database was made to identify, first, all singleton pregnancies in which fetal karyotyping was carried out and, second, the cases where the fetal nuchal translucency was equal to or above the 95th centile for fetal crown-rump length. The prevalence and distribution of chromosomal defects were determined for each nuchal translucency category: between the 95th centile for crown-rump length and 3.4 mm, 3.5-4.4 mm, 4.5-5.4 mm, 5.5-6.4 mm, 6.5-7.4 mm, 7.5-8.4 mm, 8.5-9.4 mm, 9.5-10.4 mm, 10.5-11.4 mm, and 11.5 mm or more. RESULTS: The search identified 11,315 pregnancies. The median maternal age was 34.5 (range 15-50) years, and the median fetal crown-rump length was 64 (range 45-84) mm. The fetal karyotype was abnormal in 2,168 (19.2%) pregnancies, and the incidence of chromosomal defects increased with nuchal translucency thickness from approximately 7% for those with nuchal translucency between the 95th centile for crown-rump length and 3.4 mm to 75% for nuchal translucency of 8.5 mm or more. In the majority of fetuses with trisomy 21, the nuchal translucency thickness was less then 4.5 mm, whereas in the majority of fetuses with trisomies 13 or 18 it was 4.5-8.4 mm, and in those with Turner syndrome it was 8.5 mm or more. CONCLUSION: In fetuses with increased nuchal translucency, approximately one half of the chromosomally abnormal group is affected by defects other than trisomy 21. The distribution of nuchal translucency is different for each type of chromosomal defect. LEVEL OF EVIDENCE: II-3.     

Impact of fetal reduction on the incidence of gestational diabetes.

OBJECTIVE: To estimate the rate of gestational diabetes in triplet pregnancies and to assess the impact of fetal reduction on the incidence of this complication. METHODS: One hundred eighty-eight consecutive triplet pregnancies referred to the Sheba Medical Center between 1994 and 1998 were included. One hundred three of these pregnancies continued as triplets, whereas 85 women elected to undergo fetal reduction to twins. The incidence of gestational diabetes (based on the criteria of Carpenter and Coustan) and other outcome variables were compared between the two groups. Student t-tests and chi(2) analysis were used as appropriate. RESULTS: Mean (+/-SD) maternal age was 29.2 +/- 4.8 in the triplet group and 29.3 +/- 4.1 in the reduction group. The groups had similar median parity (1.6 +/- 1.1 in the triplet group and 1.5 +/- 0.7 in the reduction group). The rate of gestational diabetes was significantly higher in the triplet group than in the reduction group (22.3% vs 5.8%). A lower birth weight (1764 +/- 448 g vs 2208 +/- 526 g) and an earlier gestational age at delivery (33.4 +/- 2.8 weeks vs 36.0 +/- 2.8 weeks) were observed in the triplet group compared with the reduction group. CONCLUSION: The number of fetuses in multifetal pregnancies influences the incidence of gestational diabetes. These findings support the hypothesis that an increase in placental mass and, thus, an increase in diabetogenic hormones play a role in the etiology of gestational diabetes.     

Pregnancies with growth-retarded twins in breech-vertex presentation at increased risk for entanglement during delivery

The purpose of this population based study on twins born in Sweden between 1961 and 1987 was to estimate the risk to the fetuses of becoming entangled during birth, and to identify those pregnancies with an increased risk for this rare complication. By using 3 separate questionnaires, 41 of 26,428 twin pregnancies with entanglement were identified. Twins in breech-vertex presentation (group A; 29 cases) were at significantly greater risk of entanglement (chi 2 = 168.3, p less than 0.001) than twins not in breech-vertex presentation (group B; 8 in vertex-vertex, 3 in breech-breech, and 1 in vertex-breech presentation). Known risk factors for entanglement in group A were intra-uterine growth retardation, a birth weight less than 2000 g, and antenatal fetal death. Intrapartum-neonatal mortality reached 38.9% in group A (median gestational week 36); and for group B, 8.3% (median gestational week 38). Entanglement during the study period occurred in 1 of 645 twin deliveries, on average. A vaginal delivery is proposed for women with twins in breech-vertex presentation, unless other risk factors leading to an increased risk for entanglement warrant abdominal delivery.     

Diabetic pregnancy associated with increased epidermal growth factor in cord serum at term

OBJECTIVE: Epidermal growth factor is a ubiquitous mitogen that also possesses insulin-like properties. Fetal mal-growth is associated with altered epidermal growth factor levels. Maternal diabetes is frequently complicated by macrosomia, but the effect of maternal diabetes on fetal epidermal growth factor levels is not known. We studied cord serum epidermal growth factor concentrations in pregnancies complicated by diabetes and in normal pregnancies. METHODS: Cord serum epidermal growth factor concentrations were measured at birth by a sandwich-type time-resolved immunofluorometric assay in 63 pregnancies complicated by insulin-dependent diabetes mellitus, in 25 pregnancies complicated by insulin-treated gestational diabetes, and in 56 normal pregnancies. RESULTS: Cord serum epidermal growth factor correlated positively with the duration of pregnancy in diabetic and normal pregnancies. In a subgroup of women at similar gestational ages (38-39 weeks), cord serum epidermal growth factor concentrations were higher in pregnancies complicated by insulin-dependent diabetes mellitus (962 +/- 211 ng/L, P =.047; n = 9) and in pregnancies complicated by gestational diabetes (1133 +/- 115 ng/L, P =.001; n = 9) than in controls (564 +/- 75 ng/L; n = 22). In multiple regression analysis, only umbilical artery hemoglobin in diabetic pregnancies and vaginal delivery in normal pregnancies were associated with cord serum epidermal growth factor. CONCLUSION: Epidermal growth factor concentrations are higher than normal in fetuses of diabetic mothers at term. Pregnancy complications, such as hypertensive disorders, fetal hypoxia and fetal malgrowth, may not explain the rise in epidermal growth factor levels. We hypothesize that the rise in epidermal growth factor levels is a metabolic response of the fetoplacental unit to diabetes-related hyperglycemia. LEVEL OF EVIDENCE: III     

Multiple pregnancies. Neonatal morbidity and mortality]

The increase in the number of multiple pregnancies and the high incidence of prematurity in this type of pregnancy justifies a pediatric evaluation. A retrospective study (1985-1989) compared the perinatal and neonatal characteristics of children resulting from 14 multifetal (at least 3 fetuses) pregnancies, with a gestational age of less than 34 weeks, with 27 children resulting from monofetal pregnancies of the same duration. Neonatal morbidity and mortality appeared to be similar in both groups. Thus at this very early time of onset of labour (mean gestational age of 30 weeks), fetal multiplicity expressed itself neither by any particular neonatal pathology nor by malnutrition.     

Patient experience in a diabetic program project improves subsequent pregnancy outcome

There has been a notable improvement in the outcome of the pregnancies of insulin-dependent diabetics. This improvement has resulted from intensive health care programs and increased awareness among patients and health providers of the need for specialized prenatal care. We hypothesized that participation in a specialized program providing early glycemic control would benefit the patient's subsequent pregnancy, despite progression of the diabetic disease process. We prospectively studied 55 insulin-dependent diabetic patients enrolled before 9 weeks' gestation through two consecutive pregnancies: sequence 1 and sequence 2. A control group of 55 insulin-dependent diabetic patients, entering the program for the first time, were matched with the sequence 2 pregnancies of the study group by maternal age and year of pregnancy. Specific outcomes related to glycemic control in early gestation were significantly improved from sequence 1 to sequence 2 pregnancies: earlier week of entry (P = .0001), lower glycohemoglobin at 9 weeks (P = .005) and at 14 weeks (P = .02), and improved fetal outcome (decreased rate of spontaneous abortions or major malformations; P less than .01). Week of entry and glycohemoglobin at 9 and 14 weeks were also significantly improved compared with the control group. Seventy-three percent of the patients entered the program earlier in their sequence 2 pregnancies (P = .001) and had lower glycohemoglobin concentrations at 9 weeks (P = .005) compared with their sequence 1 pregnancies. Sixty-five percent of the patients in sequence 2 had advanced diabetic disease (White class D-RF), compared with 46% in sequence 1 (P less than .05) and 44% of the controls (P less than .05).(ABSTRACT TRUNCATED AT 250 WORDS)     

Gestational duration and birth weight for twins related to fetal sex.

It has been postulated that male twin pregnancies, in contrast to male singleton pregnancies, differ in some distinctive biologic sense, leading to a shorter gestational duration and a lower individual birth weight than is the case in female twin pregnancies. To test this hypothesis in a relatively large dataset, information on gestational duration and birth weight for nearly all twins born in Sweden during a 4-year period (n = 3,472 twin pairs) was collected from the Medical Birth Registry, National Board of Health and Welfare. Included in the Medical Birth Registry are all pregnancies with a duration of at least 28 completed gestational weeks, or less if the newborns are alive at birth. Male-male pregnancies had a gestational duration similar to female-female pregnancies (median difference less than 2 days). The proportions of twins with a gestational age less than 36 weeks did not differ between male-male and female-female twin pregnancies (27.3 vs. 25.3%; chi 2 = 2.2, p greater than 0.05). Male-male pairs were heavier than female-female pairs (median difference 0.1 kg), and a significantly higher proportion of female-female twin pairs weighted less than 2,500 g (45.0 vs. 39.2%; chi 2 = 17.7, p less than 0.001). The results of this study in an unselected relatively large twin population seem to indicate that fetal sex does not influence gestational duration to any significant extent. Males are heavier than females indicating that the sex has a similar effect on birth weight in twin and in singleton pregnancy.     

Obstetric management when normoglycemia is maintained in diabetic pregnant women with vascular compromise

This study presents an obstetric protocol offering better management and prediction for normoglycemic insulin-dependent patients (White Class D4, F, R, or RF) who conceived after they were diagnosed as having vascular disease secondary to diabetes mellitus. Normoglycemia was accomplished during the pregestational phase, and conception occurred only after the glycosylated hemoglobin level was documented to be normal. Normoglycemia was maintained during pregnancy in the outpatient setting through the use of blood glucose monitoring performed by the patient. The obstetric protocol emphasized three additional areas of attention: (1) assessment of fetal growth by serial uterine fundal measurement and ultrasonography at gestational weeks 21 to 22; (2) assessment of fetal movement by patient-perceived fetal movements for 1 hour a week starting at week 35, increasing to 2 hr/day at week 37, and increasing to 3 hr/day from week 38 onward; and (3) cervical assessment at week 37 and preparation for vaginal delivery. Eight patients had a creatinine clearance of less than or equal to 80 ml/min prior to conception (mean = 66 +/- 6 ml/min). By 6 to 12 weeks' gestation all eight showed an increase in creatinine clearance (mean = 91 +/- 20, p less than 0.01). There was no change in the third trimester, and postpartum creatinine clearance was at antepartum levels. Proteinuria increased significantly by the end of the first trimester in all eight women and regressed post partum. Proteinuria (greater than 150 mg/24 hr) did not occur in the 14 women with normal antepartum creatinine clearance. Of 11 women with background retinopathy, six showed improvement in retinal status by fundus stereophotography whereas five showed no change. Of 11 women with proliferative retinopathy, five improved, five required laser therapy, and one remained in stable condition. Despite hemoglobin A1 levels in the normal gestational range (3% to 7.5%), there was a significant correlation of these levels with infant birth weights. None of the 22 infants died, and only one had any perinatal disease. Thus this protocol with its emphasis on fetal growth and size resulted in improvement in both maternal and infant outcome in pregnancies complicated by diabetes mellitus with vascular compromise.     

Fetal age assessment based on ultrasound head biometry and the effect of maternal and fetal factors

BACKGROUND: Maternal height and weight have increased during the past 20 years, as has birthweight. The aim of the present study was to establish new reference charts for gestational age (GA) assessment using fetal biparietal diameter (BPD) and head circumference (HC), and to determine the effect of maternal and fetal factors on age assessment. METHODS: This was a prospective, cross-sectional study of 650 healthy women with regular menstrual periods and singleton uncomplicated pregnancies, recruited after written consent. BPD (outer-outer) and HC were measured at 10-24 weeks of gestation. We used regression analysis to construct mean curves and assess the effect of maternal and fetal factors on age assessment. RESULTS: BPD and HC were successfully measured in 642 participants. Using BPD and HC before 20 weeks, the new charts gave 3-8 days higher GA assessment than the charts presently in use, and <1 day difference compared to other recently established charts. Maternal age, multiparity, fetal gender, breech position and shape of fetal head affect GA estimation by 1-2 days when using BPD (p = 0.0001-0.02). Only maternal age and fetal gender affected GA estimation when using HC (相似文献   

Second trimester maternal serum inhibin-A in fetal anemia secondary to hemoglobin Bart’s disease

Abstract

Objective: To compare the levels of inhibin-A between pregnancies with fetal anemia secondary to Hb Bart’s disease and pregnancies with normal non-anemic fetuses.

Methods: Sixty-five pregnancies at risk of fetal Hb Bart’s disease scheduled for cordocentesis at 18–22 weeks were prospectively recruited into the study. Inhibin-A levels were measured from maternal blood drawn before cordocentesis. Fetal blood samples were collected for fetal Hb typing and hemoglobin (Hb) levels.

Results: Maternal serum inhibin-A was significantly higher in women with fetal Hb Bart’s disease than those with unaffected fetuses (1.03?MoM (multiple of median) and 0.75 MoM, respectively, p?=?0.001). The relationship between maternal serum inhibin-A and fetal Hb level was a quadratic equation; inhibin-A?=?5.248?–?9.415(Hb)?+?4.919(Hb)² (r²?=?0.274, p?<?0.001). Maternal serum inhibin-A did not correlate with cardiomegaly but was significantly associated with placental thickness; inhibin-A?=?1.372?–?0.751(Pl)?+?0.214(Pl)² (r²?=?0.237, p?=?0.007).

Conclusions: Maternal serum inhibin-A levels were significantly higher in pregnancies with fetal Hb Bart’s disease. The elevation of inhibin-A was likely to be a consequence of fetal anemia and placentomegaly. Since inhibin-A is commonly used as a component of quadruple test; the calculated risk of Down’s syndrome may be unreliable in pregnancies with fetal Hb Bart’s disease or possible fetal anemia.     

Placental function test, clinical and biochemical parameters in diabetic pregnancy complicated by retinopathy

The pregnancy in specific-beta 1-glycoprotein (SP1) has been characterized as a beta 1 electrophoretic mobile glycoprotein with a molecular weight of 90,000 daltons. SP1 is known to be synthesized by the trophoblast. The measurement of this protein has been shown to be useful as a placental function test. At present, we have compared maternal SP1 serum levels in diabetic pregnancies between White classes A to D on the one hand and R, F on the other. A total of 37 uncomplicated pregnancies in healthy women and 32 of insulin-dependent pregnant diabetic women were examined between completed gestational weeks 8 and 41. In the diabetic group there were eleven women with diabetic retinopathy. Maternal SP1 serum levels were estimated by single radial immunodiffusion using a monospecific antiserum. In the results were integrated maternal and neonatal data such as glycemic control, glycosylated hemoglobin and insulin requirements. In each group there was a significant rise in maternal SP1 serum values in the second and the third trimester, when compared with values in the first trimester (p less than 0.01). Between the 34th and the 37th gestational week we found significantly lower SP1 values (p less than 0.05) in the retinopathic group (104.2 +/- 28.7 mg/l) in comparison with the control group (149.9 +/- 61.0 mg/l) and non-retinopathic group (139.1 +/- 41.7 mg/l).     

Twin weight discordance and maternal weight gain in twin pregnancies.

OBJECTIVE: To evaluate the association between twin weight discordance and maternal weight change during the gestational period. METHOD: One hundred forty-seven twin pregnancies (Group A: <25%, Group B: > or =25% birth weight discordance) were analyzed using Student's t-test, chi(2)-test, and two-way ANOVA at three gestational intervals: before 18 weeks, 18 to 28 weeks, and 28 weeks to birth. RESULT: There was no statistically significant difference between the two groups involving maternal age, parity, duration of pregnancy, height, pregravid weight, and conception method. Group A showed a pattern of constantly increasing maternal weight without a significant change in the twin weight discordance throughout gestation. However, Group B showed a fluctuation in maternal BMI with remarkably elevated twin weight discordance at 28 weeks to birth. CONCLUSION: The results suggest that in twin pregnancies constant maternal weight gain throughout gestation is important for maintaining a twin weight discordance of less than 25%.     

Treatment of fetal anemia in Rh isoimmunized pregnancies with intrauterine fetal blood transfusion

Introduction

Despite the availability of prophylactic rhesus immune globulin, hemolytic disease of the newborn and fetal death (hydrops fetalis) due to rhesus alloimmunization, is still a major contributor to perinatal morbidity and mortality in India. Pregnancy outcome after fetal therapy with ultrasound guided intrauterine transfusion (IUT) for fetal anemia was studied.

Methods

A prospective cohort study of 99 Rh isoimmunized pregnancies, Indirect Coomb’s test Positive (ICT > 1:16) was conducted from July 2002 to June 2007. Intensive fetal monitoring by sériai ultrasound and middle cerebral artery peak systolic velocity using Color Doppler was performed to detect fetal anemia. When necessary, invasive testing with cordocentesis for Hb, PCV was per-formed if pregnancy was less than 32–34 weeks gestation. If PCV was <30, or there was fetal hydrops, Ultrasound guided intrauterine transfusion was carried out by the intravascular (IVT) or the intraperitoneal (IPT) routes. Primary outcome variables were fetal survival in relation to gestational age and procedure related factors.

Result

Of 99 pregnancies, 43 cases (25 — hydropic, 18-nonhydropic fetuses) required 135 intrauterine blood transfusions. The rest 56 pregnancies were managed conservatively and did not need IUT. IUTs were performed when indicated starting from 16 weeks (IPT) and 21 weeks (IVT) of gestation by the intraperitoneal / intravascular routes respectively. Pre-transfusion Hb ranged from 3g% to 8g%. The amount of blood transfused varied from 10 ml to > 110 ml depending on the period of gestation and degree of fetal anemia. The number of transfusions per pregnancy was 1–7, at intervals of 1–4 weeks, till delivery at 28 to 36 weeks of gestation. Survival of hydropic babies (88%) was almost similar to those without hydrops (83.3%) Prognosis was slightly better in Rh isoimmunized pregnancies not requiring IUT (94%) compared to fetuses receiving transfusions (85.6%)

Conclusion

Intrauterine fetal blood transfusion was found to be the only life saving therapy, and very effective in the management of preterm Rh isoimmunized pregnancies. Results are comparable with the best centers in the world, hence early referral to specialized centers with expertise of specialized intensive fetal monitoring for early diagnosis of fetal anemia, and of intrauterine fetal blood transfusion are important for optimal perinatal outcome.     

Very low second-trimester maternal serum alpha-fetoprotein: Association with high birth weight

OBJECTIVE:To investigate the relationship between very low maternal serum alpha-fetoprotein levels (MSAFP), neonatal size, and possible associations with obstetric complications. METHODS: This is a retrospective case-control study in a population managed prospectively by a standardized protocol. Perinatal outcomes were compared between patients with unexplained very low MSAFP (less than or equal to 0.25 multiples of the median) and control pregnancies with normal MSAFP, matched by precise gestational age, parity, maternal age within 1 year, and gender of the newborn. RESULTS:Of the 84,909 women screened, 464 (0.55%) met the definition of very low MSAFP. On tertiary evaluation, 226 had dates reassigned by ultrasound. After exclusion of overt diabetics, patients who were not pregnant, invalidated MSAFP, and 17 patients lost to follow-up, 178 women (0.21% of the total) had true very low MSAFP. True very low MSAFP was associated with subsequent miscarriage in 67 women and with fetal aneuploidy and/or serious abnormalities in 12 patients, leaving a population of 97 women (1.14 per 1000 women screened) with unexplained very low MSAFP. Without obvious demographic or obstetric factors, these women had heavier babies, more babies above the 90th percentile, more delivery complications caused by large birth weight (41 versus 16, chi(2), P <.001) compared with gestational-age matched controls from the same screened population who had normal MSAFP. CONCLUSION:Very low MSAFP predicts an unusually high rate of large birth weight infants, with increased fetal, intrapartum, and neonatal consequences. Maternal medical conditions or obvious demographic factors do not explain these consequences. These findings suggest a role for close fetal surveillance in the third trimester and extended efforts to assess maternal and neonatal glucose status.