4D ultrasound study of fetal facial expressions at 20–24 weeks of gestation

Objective

To assess the frequency of fetal facial expressions at 20–24 weeks of gestation using four-dimensional (4D) ultrasonography and to determine whether there was any correlation between facial expression and gestational age (20–34 weeks).

Methods

The facial expressions of 23 healthy fetuses were examined using 4D ultrasound at 20–24 weeks. Each fetus was recorded continuously for 15 minutes. The frequencies of mouthing, yawning, smiling, tongue expulsion, scowling, sucking, and blinking were assessed and the data combined with those expressions observed at 25–34 weeks of gestation in two previous studies (n = 34) to determine the correlation between gestational age and each of the facial expressions.

Results

Mouthing was significantly more frequent than the other six facial expressions at 20–24 weeks (P < 0.05). Yawning was significantly more frequent than smiling, scowling, and blinking (P < 0.05), and sucking was significantly more frequent than smiling, scowling, and blinking (P < 0.05). The frequency of yawning, smiling, tongue expulsion, scowling, and blinking increased with gestational age (P < 0.05). Mouthing movement and sucking frequencies remained constant between 20 and 34 weeks.

Conclusion

Frequencies of complicated facial expressions such as smiling and scowling may increase with advancing gestation owing to the development of the fetal brain and central nervous system.     

Difference in the frequency of types of inter-twin contact at 10–13 weeks’ gestation: preliminary four-dimensional sonographic study

Objective. To evaluate the frequencies of various forms of inter-twin contact between monochorionic diamniotic (MD) and dichorionic diamniotic (DD) twins using four-dimensional (4D) sonography late in the first trimester of pregnancy.

Methods. Six MD and eight DD pregnancies were studied for 30 min with transabdominal 4D sonography at 10–11 and 12–13 weeks’ gestation. The position of one fetus relative to the other was ascertained. The frequencies of 10 types of inter-twin contact were evaluated.

Results. There was no significant difference in the position of one fetus relative to the other at 11–13 weeks’ gestation in MD and DD twins. There was a significant difference in the frequencies of head to arm contact between MD and DD twins at 12–13 weeks’ gestation (p < 0.05). There were also significant differences in head to arm, head to trunk, arm to arm, and arm to trunk contact between 10 and 11 and 12 and 13 weeks’ gestation in MD twins, respectively (p < 0.05).

Conclusions. The difference in the frequency of the type of inter-twin contact in MD and DD twins at 10–13 weeks’ gestation may be due to early fetal neuromuscular development and differentiation of the neuromuscular system. However, the data and their interpretation should be viewed with some degree of caution because of the small number of subjects studied.     

Cardiorespiratory management of infants born at 22 weeks’ gestation: The Iowa approach

The approach to clinical care of infants born at 22 weeks’ gestation must be consistent and well-designed if optimal results are to be expected. Publications from several international centers have demonstrated that, although there may be variance in aspects of care in this vulnerable population, treatment should be neither random nor inconsistent. In designing a standardized approach, careful attention should be paid to the unique anatomy, physiology, and biochemistry of this vulnerable patient population. Emerging evidence, suggesting a link between cardiopulmonary health and longer-term sequela, highlights the importance of understanding the relationship between cardiorespiratory illnesses of the 22-week infant, treatments provided, and subsequent cardiopulmonary development. In this review we will provide an overview to our approach to cardiopulmonary assessment and treatment, with a particular emphasis on the importance of early recognition of atypical phenotypes, timely interventions with evidence-based treatments, and longitudinal monitoring.     

Nomogram of fetal middle cerebral artery peak systolic velocity at 23–35 weeks of gestation in a Brazilian population: Pilot study

Objective.?To establish normative data for the peak systolic velocity of the middle cerebral artery (MCA-PSV) of fetuses in the second half of pregnancy using multiples of the median and percentile reference range.

Methods.?A cross-sectional study was performed in 90 healthy fetuses at between 23 and 35 weeks of gestation. A bi-dimensional axial scan of the brain, including the thalami and cavitas septi pellucidi was obtained. The circle of Willis was visualized using color flow mapping. Pulsed-wave Doppler velocimetry of the MCA was performed close to the artery's origin, with a beam-vessel angle below 20°. A table with the multiples of the median (MoM) of the MCA-PSV for each gestational age was generated and Pearson's correlation coefficient (r) was calculated. Regression modeling across gestational age was performed to obtain the reference values.

Results.?There was a strong correlation between the MCA-PVS and gestational age (r = 0.70; p < 0.001). Values for the MCA-PSV for the following MoM were calculated: 1.0, 1.29, 1.50, and 1.55. The MCA-PSV 2.5^th and 97.5^th centiles ranged from 24.33 cm²/s to 78.36 cm²/s, respectively, between weeks 23 and 35.

Conclusions.?A nomogram for the fetal MCA-PSV during the second half of pregnancy was generated.     

Correlation of nuchal translucency and thyroxine at 11–13 weeks of gestation

Abstract

Objective: Nuchal translucency (NT) thickness is one of the major screening markers during the first trimester that could be influenced by several factors. Here, we investigated the association between NT thickness and thyroid related hormones.

Methods: NT thickness was measured with transabdominal ultrasound in 643 pregnant women between 11 and 13 weeks of gestation. Maternal thyroxine (T4), free thyroxine (fT4) and thyroid-stimulating hormone (TSH) were evaluated. Bivariate correlations were assessed and thyroid profile was subcategorized with regard to the calculated reference ranges.

Results: An inverse relation was found between serum levels of maternal T4 with NT thickness (r?=??0.128, p?=?0.001) and CRL (r?=??0.168, p?<?0.001). TSH and hCG were also found to be correlated (Spearman’s correlation coefficient?=??0.092, p?=?0.019). Prevalence of maternal hypothyroidism and subclinical hypothyroidism were 1.1% and 3.7%, respectively.

Conclusion: Thyroid function tests are found to independently influence NT measurements in the first trimester. Assessment of hormones such as thyroxine could optimize the interpretation of screening tests for pathological conditions during pregnancy.     

Accuracy of angiogenic biomarkers at ⩽20 weeks’ gestation in predicting the risk of pre-eclampsia: A WHO multicentre study

ObjectiveTo assess the accuracy of angiogenic biomarkers to predict pre-eclampsia.DesignProspective multicentre study. From 2006 to 2009, 5121 pregnant women with risk factors for pre-eclampsia (nulliparity, diabetes, previous pre-eclampsia, chronic hypertension) from Argentina, Colombia, Peru, India, Italy, Kenya, Switzerland and Thailand had their serum tested for sFlt-1, PlGF and sEng levels and their urine for PlGF levels at ⩽20, 23–27 and 32–35 weeks’ gestation (index tests, results blinded from carers). Women were monitored for signs of pre-eclampsia, diagnosed by systolic blood pressure ⩾140 mmHg and/or diastolic blood pressure ⩾90 mmHg, and proteinuria (protein/creatinine ratio ⩾0.3, protein ⩾1 g/l, or one dipstick measurement ⩾2+) appearing after 20 weeks’ gestation. Early pre-eclampsia was defined when these signs appeared ⩽34 weeks’ gestation.Main outcome measurePre-eclampsia.ResultsPre-eclampsia was diagnosed in 198 of 5121 women tested (3.9%) of whom 47 (0.9%) developed it early. The median maternal serum concentrations of index tests were significantly altered in women who subsequently developed pre-eclampsia than in those who did not. However, the area under receiver operating characteristics curve at ⩽20 weeks’ gestation were closer to 0.5 than to 1.0 for all biomarkers both for predicting any pre-eclampsia or at ⩽34 weeks’ gestation. The corresponding sensitivity, specificity and likelihood ratios were poor. Multivariable models combining sEng with clinical features slightly improved the prediction capability.ConclusionsAngiogenic biomarkers in first half of pregnancy do not perform well enough in predicting the later development of pre-eclampsia.     

Association between bacterial vaginosis and fetal fibronectin at 24–29 weeks’ gestation

Objective: To investigate the relationship between fetal fibronectin and bacterial vaginosis, which are associated with an increased risk for preterm delivery.Methods: Researchers for the Pregnancy, Infection and Nutrition Study, a cohort study of pregnant women at three central North Carolina sites, collected genital tract specimens from all enrolled women between 24 and 29 weeks’ gestation. Among women with last menstrual periods between March 10, 1995, and August 15, 1996, 868 pregnancies were eligible for this analysis. Fetal fibronectin was assessed by a dipstick immunoassay kit. Bacterial vaginosis was evaluated by Nugent-scored, Gram-stained vaginal smears (scores of 7–10 considered positive).Results: Overall, 6.3% of women had positive fetal fibronectin test results, and 18.8% had bacterial vaginosis. The unadjusted relative risk (RR) of fetal fibronectin-positivity comparing women with bacterial vaginosis to those without bacterial vaginosis was 1.6 (95% confidence interval [CI] 1.1, 2.5). Using multiple logistic regression to adjust for race, maternal age, parity, and location of care, women who had bacterial vaginosis and smoked at the time of recruitment were at substantially increased risk of fetal fibronectin-positivity (RR 7.8, 95% CI 2.2, 27.8) compared with smokers without bacterial vaginosis. Among nonsmokers, bacterial vaginosis was not associated with fetal fibronectin-positivity (RR 1.0, 95% CI 0.4, 2.4). These results were essentially unchanged after adding the requirement of vaginal pH exceeding 4.5 to the bacterial vaginosis definition.Conclusion: Fetal fibronectin was associated positively with bacterial vaginosis, but only among women who smoked. These results might provide clues as to the biologic relationship between smoking, infection, and preterm delivery.     

Antenatal corticosteroids and perinatal outcomes in infants born at 23–25 weeks of gestation

Objectives: To evaluate the perinatal results of infants born between 23 and 25.6 weeks of gestation.

Methods: Medical charts of all women giving birth prematurely (23–25.6 w) from January 2005 to December 2011 were retrospectively reviewed. Cases of malformed infants or deliveries elsewhere were excluded.

Results: 198 infants were included. Chorioamnionitis occurred in 86 (43.4%) of the whole group: 26 (86.7%) in the 23-week; 35 (53.8%) in the 24-week and 25 (24.3%) in the 25-week groups. Foetal maturation with antenatal corticosteroids was complete in 119 cases (60.1%): 4 (13.3%) in the 23-week; 35 (53.8%) in the 24-week and 80 (77.7%) in the 25-week groups. Foetal death at birth occurred in 22 cases (11%) and 61 newborns (30.8%) died in the neonatal period. Of the 106 survivors with 2 years complete follow-up, 45 infants (42.4%) did not present sequelae; 16 infants (15.1%) had severe sequelae. A 66.6% (4) of infants born at 23 weeks of gestation did not present sequelae compared with a 32.3% (11) at 24 weeks and 45.4% (30) at 25 weeks.

Conclusions: The chorioamnionitis rate was higher when gestational age was lower. The foetal maturation rate was higher when gestational age was higher. A low severe sequelae rate was observed in the whole series, particularly in the 23-week group where the rate was lower than expected; however, these results could have been influenced by the small size of the 23-week group.     

Maternal serum placental growth hormone at 11–13 weeks’ gestation in pregnancies delivering small for gestational age neonates

Objective: To investigate whether the maternal serum concentration of human placental growth hormone (PGH) at 11–13 weeks’ gestation is altered in pregnancies that deliver small for gestational age (SGA) neonates. Methods: Maternal serum concentration of PGH was measured in 60 cases that subsequently delivered SGA neonates in the absence of preeclampsia and compared to 120 non-SGA controls. Results: In the SGA group, compared to the non-SGA group, there was no significant difference in the median PGH MoM (0.95 MoM, IQR 0.60–1.30 vs. 1.00 MoM, IQR 0.70–1.30, p = 0.97). There was no significant association between PGH MoM and birth weight percentile in either the SGA (p = 0.72) or in the non-SGA group (p = 0.63). Conclusion: Maternal serum PGH at 11–13 weeks’ gestation is unlikely to be a useful biochemical marker for early prediction of SGA.     

Combination of copeptin,placental growth factor and total annexin V microparticles for prediction of preeclampsia at 10–14 weeks of gestation

IntroductionPreeclampsia (PE) remains to be an enigmatic puzzle for clinicians and researchers perplexing them for decades. As delivery remains only choice of treatment, early prediction of PE will offer timely therapeutic invention and hence extensive research efforts have been put in identification of biomarkers which will facilitate early prediction of PE.MethodsSerum levels of CPP, PlGF and plasma total annexin V MPs were assessed in women who subsequently developed PE (n = 33), IUGR (n = 81) and normal pregnancy outcome (n = 112) at 10–14 weeks of gestation. Comparison of biomarker levels between patients and control group was done using Mann Whitney test. Receiver operating curve (ROC) analysis and binary logistic regression analysis were used to evaluate predictive utility of combination of CPP, PlGF and total annexin V MPs for prediction of PE.ResultsWomen who subsequently developed PE showed significantly elevated levels of total annexin V MPs [2766.04 (2086.88–3794) versus 1090.74 (631.91–2197.16)] and CPP [440.98 (365.12–488.92) versus 217.8 (171.13–308.98)] compared to controls. Serum PlGF levels were significantly reduced in women with PE 17.68 (12.66–22.32) compared to controls 105.22 (35.02–255.1). Using logistic regression analysis, the combination of CPP, PlGF and total annexin V MPs gave high predictive value with AUC of 0.970, 93.1% sensitivity, 90.7% specificity, 77.50% Positive predictive value, 98.10% Negative predictive value, 11.69 Positive likelihood ratio and 0.07 Negative likelihood ratio for PE prediction at 10–14 weeks.ConclusionThe combination of serum markers and plasma microparticles can be used for 10–14 weeks prediction and discrimination of PE from other pregnancy complications.     

Cytomegalovirus antibody status at 17-18 weeks of gestation and pre-eclampsia: a case-control study of pregnant women in Norway

Please cite this paper as: Strand K, Odland M, Iversen A, Nordb? S, Vik T, Austgulen R. Cytomegalovirus antibody status at 17-18?weeks of gestation and pre-eclampsia: a case-control study of pregnant women in Norway. BJOG 2012;119:1316-1323. Objective To assess the association between maternal cytomegalovirus (CMV) antibodies in mid-pregnancy and pre-eclampsia. Design Nested case-control study. Setting Pregnancies registered in the Norwegian Mother and Child Cohort Study (MoBa): a large population-based pregnancy cohort (1999-2006). Sample A cohort of 1500 women with pre-eclampsia and 1000 healthy pregnant women. Methods Plasma samples and pregnancy-related information were provided by the MoBa. Antibody status (CMV IgG and CMV IgM) and levels (CMV IgG) at 17-18?weeks of gestation were determined by enzyme-linked immunosorbent assay (ELISA). Main outcome measure A diagnosis of pre-eclampsia, as defined in the Medical Birth Registry of Norway. Results There was no evidence of an effect of CMV IgG seropositivity on the likelihood of developing pre-eclampsia, and CMV IgG antibody levels among women who were seropositive did not differ between groups. Adjusted for maternal age, parity and smoking, the odds ratio for pre-eclampsia in women seropositive for CMV IgG was 0.89 (95% CI 0.74-1.05; P?=?0.17). The proportions of women who were seropositive for IgM did not differ between women with pre-eclampsia and women who were healthy (P?=?0.98). Among nulliparous women, the proportion of women who were seropositive for CMV IgG was slightly lower among women with pre-eclampsia (53.5%) than among healthy women (59.8%) (P?=?0.03). Subgroup analyses were performed for women with early or late onset pre-eclampsia, with preterm delivery and/or with neonates that were small for gestational age, but antibody status did not differ between pre-eclampsia subtypes and controls. Conclusions The presence of maternal antibodies to CMV was not associated with pre-eclampsia in our study. The results suggest that CMV infection is unlikely to be a major cause of pre-eclampsia.     

Maternal hemoglobin at 27–29 weeks’ gestation and severity of pre-eclampsia

Objective: To examine the relationship between maternal hemoglobin concentration (Hb) at 27–29 weeks’ gestation and severity of pre-eclampsia (PE).

Methods: This was a retrospective study of maternal Hb at 27–29 week in 497 pregnancies that developed PE and 497 healthy controls with normal pregnancy outcomes. Multiple regression analysis was used to examine the association between HB and maternal characteristics and severity of PE classified according to gestation at delivery, birth weight and prevalence of abnormal peripartum maternal creatinine, aspartate transaminase and platelet count.

Results: There was no significant difference in median Hb between the PE and control groups. Multiple regression analysis in the PE group showed that significant prediction for Hb was provided by Afro-Caribbean race, gestation at delivery, maternal platelet count <2.5th percentile and birth weight, but not serum creatinine or aspartate transaminase above the 97.5th percentile. Increased Hb was observed in both small and large for gestational age neonates.

Conclusion: In PE, Hb at 27–29 weeks is influenced by birth weight, maternal characteristics and platelet count.     

C-reactive protein at 11–13 weeks’ gestation in spontaneous early preterm delivery

Objective: To examine the potential value of maternal serum level of C-reactive protein (CRP) in the first trimester of pregnancy in the prediction of spontaneous early preterm delivery. Methods: Maternal serum concentration of high-sensitivity CRP at 11–13 weeks’ gestation was measured in a case–control study of singleton pregnancies delivering phenotypically normal neonates, including 30 cases with spontaneous delivery before 34 weeks, with 15 cases presenting with contractions and 15 cases presenting with preterm premature rupture of membranes, and 90 matched controls delivering after 37 weeks. The median multiple of the median (MoM) serum CRP in the two outcome groups was compared. Results: The median serum CRP MoM was not significantly different in the spontaneous early preterm delivery group compared to the term delivery group (1.101, IQR = 0.572–1.985 vs. 0.975, IQR = 0.577–1.923; p = 0.813). The prevalence of CRP MoM above the 75th percentile was not significantly different between the early preterm delivery group compared to the term delivery group (26.7 vs. 24.4%; p = 0.811). In the preterm delivery group, the median serum CRP MoM in those presenting with contractions was not significantly different from those presenting with PPROM (1.175, IQR = 0.403–2.122 vs. 1.027, IQR = 0.659–1.940; p = 0.713). High-sensitivity CRP did not significantly improve prediction for preterm delivery over regular CRP. Conclusions: Measurement of maternal serum CRP at 11–13 weeks is unlikely to be useful in screening for spontaneous early preterm delivery.     

Transabdominal uterine arteries Doppler at 12–14th and 20–24th week of gestation and pregnancy outcome: A prospective study

Objective

To identify women at actual risk of pre-eclampsia and poor pregnancy outcome in a selected group of high risk patients.

Study design

Prospective study of women with previous pre-eclampsia and/or intra uterine growth retardation, intra uterine death (≥20th week), chronic hypertension, three or more previous spontaneous abortions. All subjects were followed-up till pregnancy outcome. Gestational week at delivery and birth weight were recorded. Other outcome measures were: intra uterine growth retardation, pregnancy-induced hypertension, pre-eclampsia, abruptio placenta, admission in neonatal intensive care unit.

Results

139 patients were enrolled and followed-up until the end of pregnancy. Abnormal Doppler results at 12–14th week examination were associated with intra uterine growth retardation, fetal death/spontaneous abortion and small for gestational age birth.

Conclusions

This study indicates that early evaluation of arterial uterine RI and presence of notches may be predictive of low birth weight and intra uterine growth retardation in a high risk population.     

A case of ruptured uterus at 27 weeks of gestation complicated by placenta accreta

Introduction  

Placenta accreta is a rare complication, which can lead to maternal morbidity and mortality.     

Subarachnoid space diameter in chromosomally abnormal fetuses at 11–13 weeks’ gestation

Objectives: To examine the subarachnoid space diameters in chromosomally abnormal fetuses at 11–13 weeks’ gestation.

Methods: Stored three-dimensional (3D) ultrasound volumes of the fetal head at 11–13 weeks’ gestation from 407 euploid and 88 chromosomally abnormal fetuses (trisomy 21, n?=?40; trisomy 18, n?=?19; trisomy 13, n?=?7; triploidy, n?=?14; Turner syndrome, n?=?8) were analyzed. The subarachnoid space diameters, measured in the sagittal and transverse planes of the fetal head, in relation to biparietal diameter (BPD) in each group of aneuploidies was compared to that in euploid fetuses. A total of 20 head volumes were randomly selected and all the measurements were recorded by two different observers to examine the interobserver variability in measurements.

Results: In euploid fetuses, the anteroposterior, transverse and sagittal diameters of the subarachnoid space increased with BPD. The median of the observed to expected diameters for BPD were significantly increased in triploidy and trisomy 13 but were not significantly altered in trisomies 21 and 18 or Turner syndrome. In triploidy, the subarachnoid space diameters for BPD were above the 95th centile of euploid fetuses in 92.9% (13 of 14) cases. The intraclass reliability or agreement was excellent for all three subarachnoid space diameters.

Conclusion: Most fetuses with triploidy at 11–13 weeks’ gestation demonstrate increased subarachnoid space diameters.     

A predictive neonatal mortality score for women with premature rupture of membranes after 22–27 weeks of gestation

Objective: Premature rupture of the membranes (PROM) remains a leading cause of neonatal morbidity. The objectives of the present study were to analyze the outcomes of pregnancies complicated by PROM between 22 and 27⁺⁶ weeks of gestation (WG) and to study antepartum risk factors that might predict neonatal death.

Patients and methods: One hundred and seven pregnancies were analyzed over a 3-year period in a tertiary maternity hospital. The collected maternal and neonatal data were used to model and predict the outcome of PROM.

Results: Prevalence of PROM (for live births) was 1.08%, and the overall survival rate was 59.8%. From preselected candidate variables, gestational age (GA) at PROM (p?=?.0002), a positive vaginal culture for pathogenic bacteria (p?=?.01), primiparity (p?=?.02), and the quantity of amniotic fluid (p?=?.03) were included in a multivariable logistic regression analysis. The corresponding adjusted odds ratios [95% confidence interval] were, respectively, 0.91 [0.87–0.96], 11.08 [1.65–74.42], 0.55 [0.33–0.91], and 0.97 [0.95–0.99]. These parameters were used to build a predictive score for neonatal death.

Conclusions: The survival rate after PROM at 22–27⁺⁶ weeks of gestation was 59.8%. Our predictive model (built using multivariable logistic regression) may be of value for obstetricians and neonatologists counseling couples after PROM.     

Cardiac defects in chromosomally normal fetuses with increased nuchal translucency at 10–14 weeks of gestation

Objective: To examine the prevalence, distribution and spectrum of cardiac defects in chromosomally normal fetuses with increased nuchal translucency thickness. Patients and methods: During a 4-year period, targeted fetal echocardiography was used in 353 chromosomally normal fetuses with increased nuchal translucency thickness at 10-14 weeks' gestation. The cardiac scan was performed at 18-22 weeks. In the last 138 cases enrolled, an additional scan at 12-16 weeks was carried out. The follow-up included the findings at necropsy or in the pediatric examination. A complete follow-up was achieved in 97%. Results: Cardiac defects were present in 32 (9.1%) cases, increasing from 5.3% in those with a nuchal translucency thickness of ≥ 95th centile (3.9 mm) to 24% when thickness ≥ 6 mm (p < 0.001). In 31 cases (97%), the cardiac defect was diagnosed antenatally; in 24 cases (77%) this diagnosis was confirmed later. In the remaining seven cases, the autopsy examination was not available. A wide range of cardiac defects was observed, with the most common being atrioventricular septal defect and tricuspid atresia. Conclusions: Euploid fetuses with increased nuchal translucency thickness have a significantly increased risk of cardiac defects. This is a marker of different types of heart anomalies and constitutes an additional indication for targeted fetal echocardiography. Most of the cardiac defects can be detected by fetal echocardiography.