Prenatal detection of a high-risk group for intrauterine growth restriction based on sonographic fetal biometry.

OBJECTIVE: This study was performed to evaluate the significance of sonographic fetal biometry in predicting low birth weight. METHOD: Five hundred and sixty-eight single-term pregnancies were analyzed. They were stratified into seven subgroups by birth weight deviation (BWD). Among the 568 pregnancies, 115 were revealed to be small-for-gestational-age (SGA) (birth weight less than mean -1.5 S. D.). When IUGR was suspected by routine sonographic fetal biometry, 'IUGR work-up' was carried out. The diagnostic performance of our screening method for the detection of SGA pregnancies in the general population was calculated. RESULT: The sensitivity, specificity, positive predictive value, negative predictive value and odds ratio of our screening method for the detection of SGA pregnancies in the general population were 73.0, 96.6, 83.2, 98.0% and 131.0, respectively. CONCLUSION: These data suggest that sonographic biometry is useful for the prenatal detection of high-risk cases of fetal growth restriction.     

Intrauterine volume, fetal abdominal area and biparietal diameter measurements with ultrasound in the prediction of small-for-dates babies in a high-risk obstetric population.

Summary. . The value of fetal biparietal diameter and abdominal area, total intrauterine, intra-amniotic and placental volume measurements for predicting small-for-dates babies in a high-risk obstetric population was investigated in 130 women. A parallel planimetric area method was used to measure volume. The commonest risk factors were suspected intrauterine growth-retardation, hypertensive complications and previous poor obstetric history. The prevalence of birthweight at and below the 10th or 3rd centiles was 30 and 16% respectively. Fetal abdominal area and total intrauterine volume measurements had the highest and comparable sensitivity, specificity and positive predictive value in the detection of infants with birthweights of 10th and 3rd centiles. While these measurements are of use in consolidating the clinical diagnosis of small-for-dates fetuses (growth retardation), high false positive rates (10% and 16–17% for birthweights 10th centile, and 3rd centile respectively) make further discriminatory tests necessary for part of the population.     

Fetal assessment based on fetal biophysical profile scoring. IV. An analysis of perinatal morbidity and mortality

The relationship between the last biophysical profile score result and perinatal outcome was determined among a large referred population of high-risk pregnancies. A highly significant inverse linear correlation was observed for fetal distress, admission to neonatal intensive care unit, intrauterine growth retardation, 5-minute Apgar score less than 7, and umbilical cord pH less than 7.20 but not for the incidence of meconium or major anomaly. A highly significant inverse exponential (log 10) relationship was observed for perinatal mortality in total and by component parts and cause. These data strongly suggest the biophysical profile scoring method of fetal risk assessment is accurate and also provides insight into the extent of fetal compromise.     

Fetal assessment based on fetal biophysical profile scoring: experience in 12,620 referred high-risk pregnancies. I. Perinatal mortality by frequency and etiology

Fetal biophysical profile scoring was used as a method for antepartum fetal risk assessment in 12,620 high-risk patients referred in a 55-month interval. A total of 26,257 tests were performed on these patients (range, one to 18 tests per patient). Ninety-three perinatal deaths occurred (gross perinatal mortality rate, 7.37 per 1000) of which 62 (66.6%) were due to a major anomaly, seven were due to Rh disease (7.5%), and the remaining 24 deaths (25.8%) occurred in structurally normal fetuses. The corrected perinatal mortality rate was 1.90 per 1000. Eight structurally normal fetuses died within 1 week of a normal test result (corrected false negative rate, 0.634 per 1000). These data suggest fetal biophysical profile scoring is an accurate method for identification of the fetus at risk for perinatal death.     

Use of polymerase chain reaction as a diagnostic tool for neonatal sepsis can result in a decrease in use of antibiotics and total neonatal intensive care unit length of stay.

OBJECTIVE: To retrospectively determine if a negative 16S ribosomal RNA (rRNA) polymerase chain reaction (PCR) (PCR(-)) could lead to a decrease in the number of antibiotic doses and neonatal intensive care unit (NICU) length of stay (LOS) for infants admitted to the NICU for presumed early-onset sepsis (EOS) with negative blood culture results (BC(-)). STUDY DESIGN: Analysis included 419 infants, greater than 35 weeks gestational age, with PCR(-), BC(-) and LOS > 48 h. Both the investigators and clinical care team were unaware of the PCR results. The actual number of antibiotic doses (AAD) administered was compared to an estimated number of antibiotics doses (EAD) that would have been given until PCR(-) results were available by 18 h. The number of antibiotic doses saved was calculated as (AAD-EAD). The actual NICU LOS in hours (aLOS) for a subset of infants who remained in the hospital primarily for antibiotic therapy was compared to an estimated LOS (eLOS) if infants with PCR(-) were discharged from the NICU when clinically stable. The number of hours saved was calculated as (aLOS-eLOS). RESULTS: Approximately eight antibiotic doses and 85 NICU hours per infant could be saved using PCR(-) results available at 18 h. CONCLUSIONS: Use of 16S rRNA PCR could decrease the number of antibiotics doses and NICU LOS for infants admitted for EOS. This may facilitate: (1) earlier NICU discharge; (2) parental satisfaction; and (3) decreased health care costs.     

Impact on fetal mortality and cardiovascular Doppler of selective ligature of uteroplacental vessels compared with undernutrition in a rabbit model of intrauterine growth restriction

Objectives

To compare the impact on birth weight, mortality and fetal haemodynamic changes of selective ligature of uteroplacental vessels vs maternal undernutrition as experimental models of intrauterine growth restriction in the pregnant rabbit.

Methods

Three groups of NewZealand rabbit fetuses were compared: controls (n = 60), selective ligature of 40-50% of uteroplacental vessels (n = 38) and 70% diet restriction (n = 19), both starting at 25 days of gestation. Cardiovascular Doppler evaluation was performed before delivery in a subgroup of fetuses (15 controls and cases from surgical model and 10 fetuses from the undernutirtion model) before delivery including: umbilical artery pulsatility index (UAPI), middle cerebral artery pulsatility index (MCAPI), ductus venosus pulsatility index (DVPI), aortic isthmus pulsatility index (AoIPI), isovolumetric contraction time, ejection time, isovolumetric relaxation time (IRT), and myocardial performance index. Fetuses were delivered at 30 days of gestation by caesarean section and biometric measurements were recorded.

Results

The mortality rate was significantly higher in the surgical group (54.2%) than in the undernutrition (5%) and control (14.3%) groups (p < 0.001). Changes of biometrical measurements increased across experimental groups, being more pronounced in the surgical model. Ultrasound evaluation demonstrated linear trend for increased values in DVPI (p = 0.003) and AoIPI (p = 0.029), and IRT (p = 0.003) across study groups, but statistically significant changes were only observed in the surgical model. No significant differences were observed in the UAPI or MCAPI.

Conclusions

While animal models fail to perfectly reproduce the human condition, selective ligature of uteroplacental vessels reproduces more closely cardiovascular features observed in human fetuses with intrauterine growth restriction when compared with undernutrition.     

Significant fetal pulmonary regurgitation as a possible prenatal sign of aorto-pulmonary window in the fetus with intrauterine growth retardation. A case report

We report a fetal congenital heart defect - aorto-pulmonary window - found at autopsy, which coexisted with a significant holodiastolic pulmonary regurgitation seen during a routine echocardiography in a fetus with intrauterine growth retardation and multiple anomalies.     

Advanced FISH with directly labeled X, Y and 18 DNA probes as a tool for rapid prenatal diagnosis.

OBJECTIVE: To examine a rapid technique for identification and determination of fetal sex chromosomes and one autosome (chromosome 18) in uncultured amniotic fluids using fluorescence in situ hybridization (FISH) with directly labeled DNA probes and ignoring the use of proteinase K and Rnase. STUDY DESIGN: Twenty-five amniotic samples taken from pregnant women who were in their 18th gestational week and had advanced maternal age were studied for analysis of sex chromosomes and chromosome 18 with the FISH technique as well as standard cytogenetic analysis. RESULTS: Four hours after amniocentesis was performed, we identified the sex of the fetuses and disomy of chromosome 18 in a minimal sample of uncultured amniotic fluid by using directly labeled DNA probes for chromosomes X, Y and 18 (VYSIS) and ignoring the use of proteinase K and Rnase. CONCLUSION: The possibility of shortening the time required for identification of aneuploidies in a second-trimester fetus is useful in cases where fetal anomalies are ultrasonically diagnosed at a relatively advanced gestational age.     

The impact of prenatal care on fetal and neonatal death rates for uninsured patients: a "natural experiment" in West Virginia.

A three-county program in southern West Virginia was developed by an obstetric practice to deliver prenatal care to a population of uninsured patients. Between January 1984 and December 1986, 1331 (29.4%) of 4534 patients were delivered at a level 2 hospital after prenatal care within the clinic program. The hospital-wide fetal death ratio declined from 11.8 to 7.2 per 1000 live births during the years of clinic operation, a statistically significant reduction (P = .02). Uninsured patients experienced a statistically significant reduction in fetal death ratio during the program, from 35.4 to 7.0 per 1000 live births (P = .02), whereas those covered by medical assistance did not experience a reduction. Privately insured patients also had a significant decrease, from 10.0 to 3.1 per 1000 live births (P less than .001). The increasing operating expense, mainly due to rising malpractice insurance premiums, required suspension of the program in December 1986. The fetal death ratio returned to 10.3 deaths per 1000 live births in 1987. Factors that varied significantly during the "clinic" phase included: higher rates of cesarean, diagnosed maternal hypertension, and diabetes mellitus; and lower rates of premature rupture of membranes and non-white population. Other factors, including age over 35 years, postdatism, incidence of twins, incidence of lethal congenital anomalies, and single marital status, did not vary significantly before, during, or after the clinic program. This study identified a high-risk population of patients who did not qualify for medical assistance coverage and were de facto "uninsured." The results suggest that prenatal care for this high-risk population of uninsured patients can reduce the fetal death rate.     

First-trimester maternal serum human chorionic gonadotrophin as a marker for fetal chromosomal disorders. The Dutch Working Party on Prenatal Diagnosis.

The Dutch Working Party on Prenatal Diagnosis has initiated a study on the possibilities of first-trimester screening for fetal chromosomal disorders. We report on maternal serum human chorionic gonadotrophin (MS-hCG) measurements in 1348 pregnancies with a chromosomally normal fetus and 53 pregnancies with a chromosomally abnormal fetus. The median MS-hCG concentration in 24 pregnancies with Down's syndrome was 1.19 multiples of the normal median (MoM). The MS-hCG distributions in normal and Down's syndrome pregnancies did not differ significantly (t-test: t = 1.945, p greater than 0.05). We also found no difference between normal pregnancies and pregnancies with other chromosomal disorders (six cases of trisomy 18, MoM = 0.80; four cases of sex chromosome abnormality, MoM = 1.01; 17 cases of chromosomal mosaicism in chorionic villi, MoM = 1.11). Selecting an upper limit at the 90th centile could detect 25 per cent of pregnancies with Down's syndrome. We conclude that, in the first trimester, MS-hCG as a screening factor for Down's syndrome is of minor value. However, MS-hCG could be a useful factor in a first-trimester screening programme based on a combination of markers.     

Severe maternal morbidity (near miss) as a sentinel event of maternal death. An attempt to use routine data for surveillance

Background  

To identify all the records within the Brazilian Hospital Information System (HIS) that contained information suggestive of severe maternal morbidity (near miss); to describe the diagnoses and procedures used; to identify variables associated with maternal death.     

Combination chemotherapy with 5-fluorouracil, methotrexate and etoposide for patients with high-risk gestational trophoblastic tumors: a report based on our 11-year clinical experiences

OBJECTIVES: To evaluate the efficacy, toxicity, and survival of patients with high-risk gestational trophoblastic tumors (GTTs) treated with the 5-fluorouracil (5-FU), methotrexate (MTX) and etoposide (VP-16) regimen. METHODS: Between 1992 and 2003, 26 consecutive patients with FIGO-defined high-risk GTTs were treated with 5-FU, MTX and VP-16 regimen. Among them, 9 patients had received prior chemotherapy. Remission rate, causes of treatment failure, and toxicity were analyzed retrospectively. RESULTS: After treatment with 5-FU, MTX and VP-16 regimen, 21 of 26 gained complete respond (80.8%). Two patients were performed adjuvant hysterectomy and both cured ultimately. Five developed resistance (19.2%), and 1 died of widespread metastases (3.8%). All 5 patients who developed resistance were treated with multidrug regimen of etoposide, methotrexate, and actionmycin D alternating with cyclophosphamide and vincristine (the EMA/CO); 4 were salvaged and 1 died of refractory disease. No ones relapsed. WHO grade 4 leukocytopenia and thrombocytopenia with the 5-FU, MTX and VP-16 regimen occurred in 9.0% and 2.4%, respectively, of the total 167 cycles; other toxic effects were acceptable and manageable. With mean follow up of 37 months, neither relapse nor secondary tumor was observed. CONCLUSIONS: According to our 11 years of clinical observation, 5-FU, MTX and VP-16 chemotherapy is one of effective multiagent regimen for patients with high-risk GTTs. Its toxicity is mild and manageable. For patients with high-risk and refractory GTTs, this new triple salvage chemotherapy regimen may be an effective alternative.     

Intrauterine insemination with donor semen. An evaluation of prognostic factors based on a review of 1131 cycles

OBJECTIVE: To identify prognostic factors influencing the outcome of infertility treatment using intrauterine insemination with donor semen (IUI-D). DESIGN: Retrospective study of all patients undergoing IUI-D between August 1st, 1990 and July 31st, 1998. SETTING: University-affiliated infertility clinic. PATIENTS: Three hundred and five couples undergoing 1131 IUI-D treatment cycles. MAIN OUTCOME MEASURES: Type of hormonal treatment, number of follicles, length of follicular phase, endometrial pattern, female age, infertility diagnosis and semen quality related to clinical pregnancy rate, cumulative birth rate and multiple gestations. RESULTS: Throughout the nine year period the overall clinical pregnancy rate per cycle was 22.3%, with an increase from 12.9% in 1990 to 34.6% in 1998. The multiple birth rate was 20.6%. The birth rate per couple was 61.1% after a mean of 3.2 treatment cycles. The pregnancy rate was highest in the first treatment cycle and the cumulative birth rate rose only slightly after the sixth treatment cycle. The following parameters were positively and significantly correlated to a successful outcome of IUI-D: i) the first treatment cycle - compared to the following up to six treatment cycles; ii) number of mature follicles - more than one - at the time of insemination, however, with an unacceptable high rate of multiple pregnancies when more than 3 mature follicles were present; iii) time of insemination after the 12th day in the cycle; iv) insemination after ovulation has occurred and; v) female age under 30 years. CONCLUSIONS: IUI-D is a simple and inexpensive treatment giving acceptable pregnancy rates for up to six treatment cycles if at least 2 mature follicles have developed at the time of insemination, which implies that hormonal ovarian stimulation and induction of ovulation is used, and ovulation has occurred at the time of insemination, which ought to take place after cycle day (cd) 12 with at least two million motile spermatozoa.     

Formulation of a potential antipregnancy vaccine based on the beta-subunit of human chorionic gonadotropin (beta-hCG). II. Use of compounds of the muramyl dipeptide (MDP) family as adjuvants

Earlier tests of an antipregnancy vaccine consisting of the beta-subunit of human chorionic gonadotropin (beta-hCG) linked by reaction with a carbodiimide reagent to tetanus toxoid (TT) and adsorbed on Al(OH)3 resulted in antibody responses that were judged inadequate in some women. Experiments were therefore conducted to evaluate the effectiveness of additional adjuvants in increasing the antibody response. Muramyl dipeptide (MDP) and several of its analogs were formulated with the vaccine and tested in rabbits. Some of the analogs, and notably N-acetyl-normuramyl-L-alanyl-D-isoglutamine, elicited substantial increments in the ability of the antisera to bind [125I]hCG and in its ability to neutralize hCG in the rat uterine weight assay. The effectiveness of these peptides was greatest when formulated in a water-in-oil emulsion. Increments of 10 fold were attained using a vegetable oil as the oil component. The MDP analogs were much less effective as adjuvants when formulated in oil-in-water emulsions or in aqueous suspensions of the antigen. It is concluded that selected MDP analogs incorporated in a water-in-vegetable oil emulsion can markedly increase the circulating antibody response to the beta-hCG-TT vaccine.     

Rapid positive confirmation of mosaicism for a small supernumerary marker chromosome as r(8) by interphase fluorescence in situ hybridization,quantitative fluorescent polymerase chain reaction,and array comparative genomic hybridization on uncultured amniocytes in a pregnancy with fetal pyelectasis

ObjectiveThis study aimed at presenting prenatal diagnosis and molecular cytogenetic characterization of a small supernumerary marker chromosome (sSMC) derived from chromosome 8 by fluorescence in situ hybridization (FISH), quantitative fluorescent polymerase chain reaction (QF-PCR), and array comparative genomic hybridization (aCGH) on uncultured amniocytes.Materials, Methods, and ResultsA 32-year-old woman underwent amniocentesis at 19 weeks of gestation because of fetal pyelectasis. Amniocentesis revealed a de novo ring-shaped sSMC in two of 21 colonies of cultured amniocytes. Repeated amniocentesis at 22 weeks of gestation revealed a karyotype of 47,XY,+mar[8]/46,XY[32] in cultured amniocytes. Spectral karyotyping and FISH confirmed that the sSMC was derived from chromosome 8. She underwent a third amniocentesis at 26 weeks of gestation. Oligonucleotide-based aCGH analysis on uncultured amniocytes demonstrated a 43 Mb genomic gain in chromosome 8 encompassing 8p22→q12.1. Polymorphic DNA marker analysis of the uncultured amniocytes revealed a maternal origin of the sSMC and excluded uniparental disomy 8. Interphase FISH analysis showed three D8Z2 signals in 8/40 (20%) of uncultured amniocytes. The cultured amniocytes had a karyotype of 47,XY,+r(8)(p22q12.1)[3]/46,XY[37]. The pregnancy was carried to term, and an apparently normal baby, weighing 3300 g, was delivered with mild hydronephrosis but no other phenotypic abnormalities. The cord blood was found to have a karyotype of 47,XY,+r(8)(p22q12.1)[2]/46,XY[38].ConclusionPrenatal diagnosis of fetal pyelectasis should alert obstetricians of chromosome aberration. Interphase FISH, QF-PCR, and aCGH analyses on uncultured amniocytes are helpful in rapid positive confirmation of an sSMC detected at amniocentesis.     

以血清CA125、绝经状态和超声检查评分预测卵巢肿瘤患者术前恶性危险指数

目的：评价以血清CA125、绝经状态和超声评分对卵巢肿瘤患者术前恶性危险指数的预测。方法：分别计算血清CA125、绝经状态、超声评分和3者结合的恶性危险指数（RMI）RMI-1和RMI-2,用以诊断卵巢癌的敏感性、特异性和阳性预测值等。结果：随机测定卵巢良性肿瘤76例和恶性肿瘤37例。若以100为RMI的界值,RMI-1的敏感性、特异性分别为81.1%和93.4%。RMI-2分别为81.0%和89.5%。若以125为RMI界值,RMI-1的敏感性、特异性为78.3%和96.0%,RMI-2分别为81.0%和90.8%。RMI-1的诊断性能明显高于RMI-2。RMI的诊断准确性明显比CA125、绝经状态、超声评分单项者高,且可与其它评分方法相媲美。结论：RMI是术前比较简单、可靠、实用的鉴别诊断卵巢肿瘤性质的方法。