Safety of cordocentesis under ultrasound guidance for fetal blood sampling

In the present study, we attempted to assess the safety and the risk of cordocentesis under ultrasound guidance for fetal blood sampling. Forty-five cordocenteses in 43 cases were carried out. These forty-three cases included 23 nonimmunologic hydrops fetalis, 12 congenital fetal malformations, 3 chromosome aberrations, 3 Rh isoimmunization, and 2 idiopathic thrombocytopenic purpura. Gestational age when cordocentesis was performed ranged from 17 to 39 weeks of gestation. In 42 (93.3%) out of 45 procedures, pure fetal blood was obtained. Postpuncture bleeding was observed in 17 cases (37.8%). In 12 (70.6%) out of 17 cases, bleeding stopped within 2 minutes. In only one case, bleeding continued for 11 minutes and cesarean section was performed due to fetal distress. Cardiotocogram obtained after cordocentesis revealed no ominous signs in the other 44 procedures. The other complications, including premature rupture of the membranes, premature labor, and intrauterine infection, did not occur during or after this procedure. There were no cases in which any kind of injury to the placenta or umbilical cord was observed.     

Reassuring fetal middle cerebral artery doppler velocimetry in alloimmunised pregnancies: neonatal outcomes without invasive procedures

OBJECTIVE: To assess the neonatal outcome in red blood cell alloimmunised pregnancies at increased risk of fetal anaemia where invasive testing was avoided based on reassuring middle cerebral artery (MCA) Doppler velocity results. METHODS: We included 28 alloimmunised pregnant women at significant risk of fetal or neonatal anaemia who did not have invasive testing because of reassuring MCA Doppler velocimetry. Women requiring invasive testing or intrauterine transfusion were excluded. Outcome measures were admission to neonatal intensive care unit, cord haemoglobin and bilirubin levels and neonatal therapy. RESULTS: Ten neonates (36%) were anaemic at birth while 18 (64%) had normal haemoglobin. Seven neonates (25%) did not require any form of neonatal therapy, 10 (36%) had phototherapy only, 7 (25%) required exchange transfusions and 4 (14%) top-up transfusions. There were no treatment-related complications. Mean cord haemoglobin was 13.9 g/dl (range 7-18.9) and mean bilirubin was 84.1 micromol/l (range 29-192). CONCLUSION: Avoiding invasive procedures in pregnancies at risk of fetal anaemia by relying on reassuring MCA Doppler velocimetry did not result in life-threatening fetal or neonatal morbidities. The extent of neonatal therapy was acceptable. The routine use of this test can lead to less unnecessary invasive procedures in at-risk fetuses.     

Platelet-binding immunoglobulins in pregnancy-induced hypertension I. Platelet-associated IgM on fetal platelets: evidence of a fetal autoimmune reaction?

Pregnancy-induced hypertension (PIH) can be complicated by maternal or fetal thrombocytopenia, or both. In order to investigate possible immunologic causes of these thrombocytopenias, platelet-associated IgG (PAIgG) and IgM (PAIgM) were measured in mothers with PIH and in their infants and compared with those from patients with autoimmune thrombocytopenic purpura (ATP), a known immunodestructive platelet disorder. Many PIH patients (33.3%) and most ATP patients (68.1%) had elevated levels of maternal PAIgG. In both diseases, the amount of PAIgG was directly proportional with the degree of thrombocytopenia (r = 0.446 in PIH and R = 0.668 for ATP). But in neither disease did the degree of maternal thrombocytopenia correlate with the degree of neonatal thrombocytopenia (r = 0.153 for PIH and R = 0.175 for ATP). Umbilical cord samples from PIH patients contained PAIgG (53.3%) and PAIgM (53.8%), whereas the umbilical cord samples from ATP patients had elevated amounts of PAIgG but not PAIgM. PAIgM in the umbilical cord blood could not be accounted for by IgM rheumatoid factors, IgM-containing immune complexes, or non-specific adsorption because of elevated total IgM levels. The umbilical cord blood PAIgM was probably not of maternal origin because it was observed even when the maternal blood contained no PAIgM and maternal IgM is not normally transported transplacentally. Therefore, the PAIgM appears to be of fetal origin. These results suggest that both maternal and fetal immunologic mechanisms may be involved in PIH-induced thrombocytopenia; if so, this is one of the first reported examples of a possible fetal autoimmune response.     

Current obstetrical practice and umbilical cord prolapse

The aim of this study was to assess the contribution of current obstetrical practice to the occurrence and complications of umbilical cord prolapse. Maternal and neonatal charts of 87 pregnancies complicated by true umbilical cord prolapse during a 5-year period were reviewed. Twin gestation and noncephalic presentations were common features (14 and 41%, respectively). Eighty-nine percent (77) of infants were delivered by cesarean section of which 29% were classical and 88% were primary. The mean gestational age at delivery was 34.0 +/- 6.0 weeks, and the mean birth weight was 2318 +/- 1159 g. Obstetrical intervention preceded 41 (47%) cases (the obstetrical intervention group): amniotomy (9), scalp electrode application (4), intrauterine pressure catheter insertion (6), attempted external cephalic version (7), expectant management of preterm premature rupture of membranes (14), manual rotation of the fetal head (1), and amnioreduction (1). There were 11 perinatal deaths. Thirty-three percent of the infants (32) had a 5-min Apgar score < 7 and 34% had a cord pH < 7.20. Neonatal seizures, intracerebral hemorrhage, necrotizing enterocolitis, hyaline membrane disease, persistent fetal circulation, sepsis, assisted ventilation, and perinatal mortality were comparable in the "obstetrical intervention" and "no-intervention" groups. Most of the neonatal complications occurred in infants < 32 weeks' gestation. We conclude that obstetrical intervention contributes to 47% of umbilical cord prolapse cases; however, it does not increase the associated perinatal morbidity and mortality.     

Meta-analysis of sex difference in testosterone levels in umbilical cord blood

This meta-analysis reviewed published literature comparing human male and female umbilical cord total testosterone (T) levels. A total of 18 studies using 1,229 samples from 602 male and 627 female newborns were analysed using the RevMan 5 statistical package. Analysis using the inverse variance method based on a random-effects model revealed significantly higher cord T in boys than girls at a moderate effect size (Hedges' g = 0.57). There was significant heterogeneity between the 18 studies, although the five studies using direct assays showed no heterogeneity. For studies using extraction and chromatography, those that combined T from arterial and venous cord blood found a larger sex difference than those using only cord venous samples (Hedges' g = 0.94 vs 0.32); this suggests umbilical cord venous T is of maternal/placental origin and arterial T is of fetal origin. The wide range of T values between studies suggests high cross-reactivity in the assay methods reviewed.     

Absence of maternal cell contamination in mesenchymal stromal cell cultures derived from equine umbilical cord tissue

This study aimed to determine whether maternal cell contamination exists in cells derived from equine umbilical cord tissue, a perspective material for cell-based therapies in veterinary medicine. Potential maternal cell contamination was analyzed at DNA level via a set of 16 microsatellite markers in cells originating from the cord tissue of 22 foals. In these cells no maternal cell contamination was detected at a sensitivity level of 0.01%. Our results suggest that equine umbilical cord tissue-derived cells are entirely of fetal origin.     

Effect of serum source on human fertilization and embryonic growth parameters in vitro

A total of 100 mature oocytes from 13 consecutive patients were randomly assigned from each patient to one of two treatment groups (n = 53 for group 1, n = 47 for group 2). Group 1 oocytes were incubated throughout the culture periods in medium supplemented with 7.5% homologous patient serum. Group 2 oocytes were treated similarly, except the serum supplement was of fetal cord origin. End points for examination included fertilization frequency, normality of fertilization, stage of embryonic development at two time periods, and quality of embryonic development at two time periods. None of the end points examined revealed significant differences between patient serum and fetal cord serum.     

斑点核酸杂交技术检测胎儿巨细胞病毒感染的研究

用￣３２Ｐ标记的巨细胞病毒（ＣＭＶ）探针通过斑点核酸杂交技术，对胎盘、脐血及胎儿组织中的ＣＭＶＤＮＡ进行了检测。结果表明，死胎、胎儿畸形的５２份胎盘组织及４８份胎肾组织中ＣＭＶＤＮＡ阳性者分别为４份及５份，正常好妊娠组（早、晚期人耳流产与足月产）的７７份胎盘及３２份胎肾组织中ＣＭＶＤＮＡ均为阴性，同一病例胎盘与胎肾组织中ＣＭＶＤＮＡ均阳性者３例。２例畸形胎儿脐血白细胞中ＣＭＶＤＮＡ阳性者１例，另一例胎儿畸形脑组织及腮腺组织中ＣＭＶＤＮＡ阳性，而正常足月产的２４例脐血白细胞中ＣＭＶＤＮＡ均阴性。共诊断８例胎儿感染ＣＭＶ，正常妊娠组无１例胎儿感染ＣＭＶ，从分子水平上证实ＣＭＶ是致死胎与胎儿畸形的重要病原。     

Acute cerebral redistribution in response to invasive procedures in the human fetus.

OBJECTIVES: We sought to investigate the fetal hemodynamic response to the acute stress of invasive procedures. STUDY DESIGN: The middle cerebral artery pulsatility index was measured by Doppler ultrasonography before and after 136 invasive procedures (fetal blood sampling, transfusion, shunt insertion, tissue biopsy, and ovarian cyst aspiration). The response of fetuses submitted to invasive procedures involving transgression of the fetal body, such as intrahepatic vein blood sampling, was compared with that of control procedures at the placental cord insertion. RESULTS: The middle cerebral artery pulsatility index value fell with fetal blood sampling performed at the intrahepatic vein (median, -0.26; 95% confidence interval, -0.35 to -0.15) but not at the placental cord insertion (median, 0.05; 95% confidence interval, -0.04 to 0.19). With transfusions, the middle cerebral artery pulsatility index also fell with procedures at the intrahepatic vein (mean, -0.51; 95% confidence interval, -0.66 to -0.35) but not at the placental cord insertion (mean, -0.04; 95% confidence interval, -0.23 to 0.14). The magnitude of the response was greater with transfusions than with blood sampling alone. The middle cerebral artery pulsatility index value also fell with non-fetal blood sampling procedures involving transgression of the fetal body (mean, -0.32; 95% confidence interval, -0.56 to -0.09) but not with control non-fetal blood sampling procedures. The change in the middle cerebral artery pulsatility index was not related to gestational age, with the youngest fetus showing a fall in the middle cerebral artery pulsatility index value being at 16 weeks' gestation. Although the degree of response was weakly correlated with the duration of needling (y = -0.21 - 0.00014x; R (2) = 0.08; P =.02), multiple logistic regression demonstrated that this was instead a function of the type of the procedure. A response was seen within 70 seconds of fetal puncture. The fetal heart rate did not change significantly with procedures in any of the above-mentioned groups. CONCLUSIONS: The human fetus mounts a cerebral hemodynamic response to invasive procedures involving transgression of the fetal body, which is consistent with the brain-sparing effect.     

Umbilical cord knots

BACKGROUND: Umbilical cord knots may represent a hazard to the fetus, particularly as regards intrauterine death and fetal distress or asphyxia in labor. The object of this study was to analyze the impact of associated umbilical cord encirclements and cord length on fetal outcome and fetal weight deviation. METHODS: Among 22,012 births occurring in Akershus Central Hospital, there were 216 instances of umbilical cord knots. Fetal outcome, fetal weight deviation, associated umbilical cord encirclements and cord length were assessed. RESULTS: Neonates with a knotted cord are more often large-for-gestational age compared to other babies, and have longer umbilical cords. There is a 10 times higher chance of intrauterine fetal death with a knotted cord, but if this does not occur then there is no increased risk of obstetrical intervention and Apgar scores are the same as in other babies and other fetuses. CONCLUSION: There is an association between umbilical cord knots and umbilical cord encirclements. Knotting of the cord is not by itself lethal. Pregnancies with knotted cords have characteristics different from those with ordinary umbilical cord encirclements.     

Predisposing factors and effects of fetal bradycardia following cordocentesis at mid-pregnancy

Objectives: To identify predisposing factors of fetal bradycardia following cordocentesis at mid-pregnancy and to compare the pregnancy outcomes to those without bradycardia. Methods: All cordocenteses performed at 18–22 weeks of gestation were prospectively enrolled. The inclusion criteria consisted of: (i) singleton pregnancies; (ii) no fetal structural or chromosomal abnormalities; (iii) the procedures done by experienced operators. They were divided into two groups; procedures with fetal bradycardia (Group 1) and those without bradycardia (Group 2). Factors related to bradycardia were identified and pregnancy outcomes between the two groups were also compared. Results: Of 6147 cordocenteses recruited, 2829 met the inclusion criteria. Of these,152 had fetal bradycardia whereas the remaining 2677 did not. The procedures involving placenta penetration, and umbilical cord bleeding were significantly related to a higher rate of fetal bradycardia. On the other hand, cordocenteses with fetal bradycardia had a significantly higher rate of fetal loss (11.8 vs. 1.9%, respectively, p = 0.001) as well as a higher rate of low birth weight and preterm birth. Conclusions: Cordocentesis with placenta penetration and umbilical cord bleeding carries a higher risk for fetal bradycardia and fetal bradycardia was an independent factor for a higher rate of fetal loss, preterm birth and low birth weight.     

The fetal intrahepatic umbilical vein as an alternative to cord needling for prenatal diagnosis and therapy

Seventy-one fetal blood samplings (FBS) were attempted from the intrahepatic portion of the umbilical vein (IHV) at 18-34 weeks; 54 were attempted primarily and 17 secondarily after a failed attempt at the placental cord insertion. Fetal blood was obtained in 89 per cent of the cases. Intravascular transfusion (IVT) was attempted on 31 occasions and successful in 24 (77 per cent). In all cases of failed sampling or transfusion via the IHV, prenatal diagnosis and/or therapy was accomplished using alternative procedures. On only one occasion was the procedure postponed. There were no losses or neonatal morbidity attributable to the procedure. FBS from the IHV may be considered as an alternative approach to sampling the placental cord insertion. It is recommended in cases where the approach to the placental cord insertion is difficult or hazardous.     

Safety of fetal blood sampling by cordocentesis in fetuses with single umbilical arteries

OBJECTIVES: To examine the safety of cordocentesis in fetuses with single umbilical arteries. METHODS: Retrospective analysis of all cases of cordocenteses in fetuses with single umbilical arteries over a five-year period at one centre. We analysed the records for pregnancy details, outcomes, and procedure-related complications, and compared these to similar data for cordocenteses procedures performed, during the same period, for similar indications in fetuses with three-vessel cords. RESULTS: Twenty-nine eligible cases were identified. All procedures were performed for the indication of fetal structural abnormalities, and seven fetuses (24%) had abnormal karyotypes. The median gestational age at the time of the procedure was 21 weeks (range 19-34 weeks). There were no procedure-related fetal losses but the umbilical artery was inadvertently punctured in one case, resulting in prolonged bradycardia with spontaneous recovery. These outcomes compare favourably to those of a total of 134 cordocenteses procedures in fetuses with three-vessel cords. CONCLUSION: Cordocentesis in cases with single umbilical arteries does not appear to carry more risk than in cases with three-vessel cord, and should continue to be performed by adequately trained specialists when indicated. Extra care should be undertaken to avoid puncturing the umbilical artery.     

Clinical significance of fetal heart rate patterns during labor. VIII. Breech presentations

The fetal heart rate (FHR) tracings of 302 consecutive breech presentations were analyzed to assess their potential value in clinical practice. There were 274 singleton births, 27 first twins and 1 triplet. Ten percent of the gestations were greater than or equal to 42 weeks, and 26% were less than or equal to 36 weeks. Infants premature by weight (less than 2,500 gm) made up 32%. Only 33.3% had no decelerations, and 63.0% had variable or variable-late decelerations. The latter group had a significantly higher incidence of depressed neonates and neonatal deaths. When accelerations were present, there were significantly fewer depressed infants and neonatal deaths. Overall the perinatal mortality (PNM) was 7.9%; for premature infants it was 27%, postterm 3% and term 1%. There was a 31% incidence of cesarean section. The PNM, when analyzed according to route of delivery, was no different for the very-low-birth-weight, low-birth-weight and term infants. Weight-specific mortality accounted for the apparent difference among the very-low-birth-weight infants. The high incidence and pathophysiology of cord compression (for first- and second-stage labor) may explain the higher incidence of depression in breeches as compared to cephalics. FHR monitoring should be done throughout delivery in order for the physicians to intervene on time when fetal distress is imminent.     

Cord prolapse: is antenatal diagnosis possible?

Cord presentation was diagnosed antenatally in nine patients at term referred for fetal ultrasound assessment (incidence of 0.61%). Seven patients were delivered by cesarean section; cord position was confirmed in four and suspected in three patients. There were two vaginal deliveries, one following spontaneous version and the other a stillbirth associated with cord prolapse.     

Decreased fetal movements in the third trimester: what to do?

OBJECTIVE: To appreciate at the end of pregnancy, in a low-risk pregnant population, the interest of a screening for fetal well-being in case of decreased fetal movements. To define the most adapted screening. PATIENTS AND METHODS: Retrospective study over a complete year of the patients having consulted in the same center for decreased fetal movements and subjected to the same screening for fetal activity in hospitalization during 48 hours. This screening included a study of fetal heart rate repeated three times a day, a fetal biophysical profile scoring, an umbilical artery Doppler, a Kleihauer-Betke testing, and an amnioscopy. RESULTS: One hundred and sixty patients were identified, representing 6.1% of pregnancies followed in the center. There was no relation between the age, the parity of the patients and the probability to consult for a decrease of fetal movements. Nevertheless the antecedents of pathological pregnancy or fetal malformation were frequent. Twenty-one percent of the deliveries were induced for a global rate of 18% in the center. Twenty-eight percent of the patients had a cesarean section for a global rate of 22.8%. Five percent of fetuses were at risk for prenatal asphyxia on the data of the screening. Fetal heart rate was abnormal in 3.75% of cases, fetal biophysical profile score pathological in 3.1% of cases. Just one umbilical Doppler was highly pathological. No meconium amniotic fluid was found. Two Kleihauer-Betke tests were disturbing. At the time of delivery, 28% of fetuses presented a funicular abnormality, 4.3% a severe growth restriction, 4.3% a malformation. One child only had an anemia. There was no perinatal mortality. DISCUSSION AND CONCLUSION: Screening for fetal vitality remains necessary in case of decreased fetal movements. It has to associate the study of fetal heart rate and the fetal biophysical profile with a Kleihauer-Betke testing. In a low-risk pregnant population, the study of fetal Doppler velocimetry is not profitable. Amnioscopy presents not enough interest. It is necessary to insist with the patients on the necessity of consulting in case of decreased fetal movements even in the approach of the term.     

Intravenous pancuronium bromide for fetal neuromuscular blockade during intrauterine transfusion for red-cell alloimmunization

Intravenous pancuronium bromide was administered into the umbilical cord by funipuncture to effect temporary fetal paralysis. Neuromuscular blockade was achieved in 12 fetuses undergoing a total of 34 intrauterine procedures for the treatment of severe red-cell alloimmunization. The same initial dose of 0.2 mg/kg fetal weight estimated by ultrasound was used in all cases, but anemic fetuses did not resume movement for prolonged periods. A relationship among fetal hematocrit, adjusted dose, and duration of paralysis was described by the equation: Duration (hours) = 5.24 + 10.30 adjusted dose (mg/kg) - 0.16 hematocrit (%) (R2 = 0.49; P less than .001). Intravenous pancuronium was found to be a safe and effective method for cessation of fetal movement during intrauterine procedures.     

Oral clindamycin and histologic chorioamnionitis in women with abnormal vaginal flora

OBJECTIVE: Oral clindamycin reduced late miscarriage and preterm birth in asymptomatic women with bacterial vaginosis or intermediate flora. We investigated whether clindamycin reduced the incidence of histologic chorioamnionitis as a mechanism for these beneficial effects. METHODS: This was a subanalysis of 126 participants from a larger randomized controlled trial. We compared the incidence of histologic chorioamnionitis between the clindamycin and placebo groups. Histologic chorioamnionitis was diagnosed by the presence of polymorphonuclear leukocytes, separately in the amnion and chorion, decidua, fetal surface of the placenta, the walls of fetal chorionic vessels, umbilical cord, or in the subchorionic fibrin layer. Microbiologic cultures were done on swabs from the space between the chorion and amnion layers. RESULTS: Histopathologic results were available for 122 placentas, 62 (51%) and 60 (49%) in the clindamycin and placebo groups, respectively. There were no significant differences in inflammation between the groups in the decidua (41% compared with 43%), membranes (25% compared with 41%), fetal vessels (16% compared with 14%), or subchorionic fibrin (32% compared with 34%). Adjusting for gestational age, ethnic origin, or history of miscarriage did not alter the results. There were no significant differences in the outcomes of pregnancy between women with and without inflammation, either before or after adjustment for treatment group. CONCLUSION: Although oral clindamycin reduced late miscarriage and preterm birth in women with abnormal vaginal flora, this effect is unlikely to be mediated through a reduction in the incidence of histologic chorioamnionitis. The relatively small size of the groups, however, does not allow us to rule out a real effect, especially given the lower rate of membrane inflammation observed in the clindamycin group. LEVEL OF EVIDENCE: I.     

Efficacy and safety of cordocentesis for prenatal diagnosis.

OBJECTIVE: To assess the efficacy and safety of diagnostic cordocentesis. METHODS: Between January 1991 and May 2004, 2,010 cordocentesis were performed in the outpatient setting in 2,010 women with singleton pregnancies. A fixed needle guide and a 22-gauge percutaneous needle were used and no more than 2 attempts were allowed at 1 visit. In most cases, the umbilical vein was the target vessel. The results of each procedure and pregnancy outcomes were recorded and analyzed. RESULTS: The most frequent indication for cordocentesis was risk of severe thalassemia (59.0%), followed by a need for rapid karyotyping (30.0%). Most of the procedures (97%) were performed in the free cord loop and the remaining at the cord insertion. The overall success rate was 98.4%, with 80.0% of the successful procedures performed at the first needle insertion and the remaining 20% at the second insertion. Transient bleeding was observed at the puncture site in 19.8% of cases and transient fetal bradycardia in 4.9% of cases. The total fetal loss and cordocentesis-related loss rates within 2 weeks of cordocentesis were 2.7% and 1.0%, respectively, before 24 weeks of gestation and 1.9% and 0.8% after 24 weeks. The other obstetric complications were unremarkable. CONCLUSIONS: Cordocentesis is a simple, safe, and reliable procedure for prenatal diagnosis.     

The relationship between fetal biophysical assessment, umbilical artery velocimetry, and fetal acidosis

In a prospective study of 62 patients undergoing cesarean delivery before the onset of labor, fetal biophysical assessment and umbilical artery systolic-diastolic ratios (S/Ds) were performed within 3 hours of delivery. There was a significant relationship between the fetal biophysical profile score and cord arterial as well as cord venous pH. However, there was no identifiable relationship between S/D and cord arterial or venous pH. The efficacies of the biophysical components alone (nonstress test [NST] and fetal biophysical profile) and in combination with S/D to predict fetal acidosis were determined. The NST had the best sensitivity (100%) and negative predictive value (100%). The fetal biophysical profile had the best specificity (91%), positive predictive value (62%), and overall efficiency (90%). The S/D had the lowest sensitivity (66%), specificity (42%), positive predictive value (16%), negative predictive value (88%), and overall efficiency (45%). The addition of S/D to the NST or fetal biophysical profile did not improve diagnostic accuracy. These data suggest that the NST should be used as a primary test for the antepartum detection of fetal acidosis, whereas the fetal biophysical profile is a reasonable adjunct test. The umbilical artery S/D, as determined by continuous-wave Doppler velocimetry, has no value as a primary method or an adjunct in the antepartum detection of fetal acidosis.