Search

We present our experience with 60 trials of external cephalic version under tocolysis (EVT) performed on 58 women with uncomplicated (low-risk) pregnancies at term (37 to 42 weeks) during a 10-month period. Version was successful in 67.2% of the subjects (70.7% of trials). Fetal well-being was monitored before, during and after the procedure by cardiotocography and real-time ultrasound (RTUS). No analgetic or anesthetic medication was administered. Transient fetal bradycardia was recorded in 18 women. No major complications were noted. Compared with the period preceding the protocol, the breech rate declined during the study period by 1.02% (P less than 0.02) with a parallel decline of 1.12% (P less than 0.001) in the low-risk breech group affected by the protocol. The cesarean section rate for low-risk breeches fell from 1.85 to 0.89% (P less than 0.001), while the overall cesarean section rate decreased from 10.15 to 9.1% (not significant). We conclude from our experience and previous studies that EVT/RTUS is a reasonable alternative in the management of pathological presentations near term, provided that only low-risk pregnancies are included, and analgesia or anesthesia for external version under tocolysis is avoided.

During the 21 years of national newborn screening for phenylketonuria (PKU) in Israel, originally supported by grants from the NIH, Washington (HEW-WA/CB-Israel-9, 1964–1967) and subsequently taken up by the Israeli Ministry of Health (Cohen et al., 1966) an average of over 95% coverage was achieved by 1979, revealing 85 cases of classical PKU, 20 of variant or atypical PKU, and 2 cases of malignant PKU with a biopterin synthetase deficiency (Cohen et al., 1985). In addition, there were 18 cases of high hyperphenylalaninaemia (HPA) with blood phenylalanine levels of 12–16 mg/dL who had never been on diet and 132 mild persistent HPA with blood phenylalanine below 12 mg/dL. No cases of classical PKU have been found amongst ‘pure’ Ashkenazi families whereas atypical and mild HPA are frequently found. Thus, the two classical PKU cases in mixed Ashkenazi families may be due to a double heterozygote effect for the PKU and HPA gene (Cohen et al, 1978)

During a 3-year period, 377 samples of amniotic fluid, free of blood and meconium and obtained from a total of 471 patients, were examined by the fluorescence polarization technique to estimate fetal lung maturity. Fluorescence polarization values of 287 samples from normal and abnormal pregnancies were correlated with gestational age. A total of 272 pregnancies comprising cases complicated by toxemia, placental insufficiency, placenta previa, premature contractions, and diabetes mellitus, and including a control group of 37, were studied to discern the effect of such pathologic conditions on the usual decline of fluorescence polarization (FP) values with increasing gestational age. No complicated pregnancy had values significantly different from those of the control group, except for pregnancies complicated by diabetes mellitus. The threshold of fetal lung maturity as related to respiratory distress syndrome (RDS) was determined in correlation with the lecithin: sphingomyelin (L:S) ratio. FP values of 0.311 +/- .005 corresponded to an L:S ratio of 2.0. An FP value of 0.316 +/- .005 is recommended as a practical threshold related to the clinical outcome of the newborn as regards RDS. The technique was found reliable, simple, and accurate and has been of great value in the antenatal diagnosis of fetal lung maturity.

High-speed centrifugation of amniotic fluid enables separation of surfactant-containing lamellar bodies. Fifty-three amniotic fluid samples from pregnancies of 28 to 39 weeks' gestation were examined for fetal lung maturity by measuring fluorescence polarization (P). For each sample the P value was determined at 37C on both the whole amniotic fluid and on the surfactant-containing lamellar bodies obtained by centrifugation at 10,000 X g. A close linear correlation (r = 0.80) was found between the P value of the amniotic fluid samples and that of the lamellar bodies. There was no difference in the specificity for discrimination of hyaline membrane disease cases by both methods (93.5%) with 95% confidence limits of 82.1 to 98.6%. Because high-speed centrifugation enables the selective sedimentation of pulmonary surfactant, determination of the lamellar body P value may offer a practical solution for the estimation of fetal lung maturity in amniotic fluid samples contaminated with blood.

The fluorescence polarization of amniotic fluid, a measure of fetal lung maturity, was determined in 518 amniotic fluid samples obtained by amniocentesis. The subjects were divided into seven clinical groups: premature contractions, premature rupture of the membranes, pregnancy-induced hypertension, diabetes, intrauterine growth retardation, vaginal bleeding, and "other" for gestational-age groups of 30 weeks or less, 31-36 weeks, and 37 or more weeks. The proportion of mature values (fluorescence polarization 0.285 or lower) increased progressively from 12.5% at 27-28 weeks to 100% at 39-40 weeks. In the 31-36-week gestation group, the proportion of mature values in subjects with premature rupture of the membranes (84.6%) was significantly higher than in those with premature contractions (60%), severe pregnancy-induced hypertension (50%), mild pregnancy-induced hypertension (55.2%), diabetes class A (50%), insulin-dependent diabetes (60%), and other (63.5%). The mean +/- SD fluorescence polarization value was significantly lower in premature rupture of the membranes (0.256 +/- 0.030) than in premature contractions (0.274 +/- 0.032), mild and severe pregnancy-induced hypertension (0.280 +/- 0.027 and 0.280 +/- 0.035, respectively), and class A and insulin-dependent diabetes (0.285 +/- 0.018 and 0.277 +/- 0.030, respectively). The severity of pregnancy-induced hypertension and diabetes did not appear to influence either the fluorescence polarization value or the proportion of mature results. With the exception of a marked influence of premature rupture of the membranes, abnormal pregnancy conditions did not appear to have a significant effect on fluorescence polarization of amniotic fluid.

Thirty-one patients with severe mechanical infertility were treated with clomiphene citrate and human chorionic gonadotropin (HCG) at the start of our in vitro-fertilization and embryo-transfer program. Laparoscopies were performed 34 to 36 h after HCG administration in 32 cases, oocytes were recovered in 29 (91%) and in 19 (59%) at least one oocyte was fertilized. Embryos were transferred to the uterus in 12 cases (38%) and a pregnancy was established in a woman in whom 3 embryos were transferred. This pregnancy terminated at the 39th week of gestation with the delivery of a healthy female baby.

Determination of fetal lung maturity by measurement of the fluorescence polarization (P) value of the amniotic fluid at room temperature has become the method of choice in an increasing number of perinatal units because of its simplicity and relatively high predictive value. Nevertheless, its power to discriminate between cases with and without hyaline membrane disease (HMD) needs improvement. To this end, we assessed the discriminative power of the P value at the physiological temperature of 37 degrees C (P37) as compared with the power at 25 degrees C (P25). The study group consisted of 288 consecutive cases at risk for preterm delivery. Samples from all 288 cases were measured at 25 degrees C and samples from 112 of these were measured concurrently at 37 degrees C as well. HMD occurred in 27 infants of the total group, nine of whom belonged to the subgroup tested at both temperatures. When sensitivity was fixed at 100% the specificity of P37 was 97% as compared to 79% for P25 (p less than 0.001). The percentage of cases with infants free of HMD who had borderline P values was also significantly smaller: 1% vs 21%, respectively (p less than 0.001). Although data on more HMD cases are needed to establish the precise threshold of lung maturity for P37, we conclude that P37 is a considerably better discriminator for fetal lung maturity determination than P25.

A unique case of triplet pregnancy in a woman with uterus didelphys is described, with fetuses A and B in the right uterine horn and fetus C in the left horn. Missed abortion of fetus A was diagnosed in the 22nd week of gestation by real-time ultrasonography, but only in the 27th week of gestation did the right uterine horn contract, resulting in expulsion of fetus A. Fetus B was delivered by cesarean section 2 hours later. Fetus C remained in the left uterine horn until the 37th week of gestation, when a viable 2490-g female infant was delivered by cesarean section. Triplet pregnancy occurs with sufficient frequency to be unremarkable; however, triplet pregnancy in a patient with uterus didelphys and with 72 days' lapse between the delivery of the first 2 fetuses and delivery of the third is a rare occurrence.

Internal podalic version of the second twin in transverse lie has usually been performed after first rupturing the membranes of the second amniotic sac. In a prospective study on internal podalic version with unruptured amniotic membranes, 11 second-born twins in transverse lie were successfully delivered, with good neonatal outcome and without birth injuries. From our experience, it appears that this modified technique, when used within the presented guidelines, offers a reasonable alternative for the safe delivery of the second twin.

Concurrent intra and extrauterine pregnancies have always been thought to be rare with a mean annual incidence of 1:30.000. The condition has been reported more frequently in the recent literature. If the incidence is increasing it is a serious development as the condition is often undiagnosed. The paper describes 5 patients with the condition presenting between 1976-1981 an incidence of 1:4000 deliveries. In two of these five patients the intrauterine pregnancy was diagnosed first and the ectopic pregnancy was undiagnosed until much later. The presence of intrauterine pregnancy often leads us to ignore the possibility of a concurrent extrauterine pregnancy. Considering that ectopic pregnancy may still cause maternal death, we believe that the condition has to be considered more often. Certain features may suggest the diagnosis. 1) Lack of vaginal bleeding or uterus larger than 9 week size with a proven ectopic pregnancy. 2) Presence of two corpora lutea at laparoscopy. 3) Ultrasound to diagnose an adnexal mass. 4) Failure of serum hCG to return to normal after abortion. The text also discusses the natural history of the condition and the higher incidence expected in the future with the wider use of ovulation inducing agents.

This is a retrospective study on 352 infertile women who were treated with HMG-hCG (Human Menopausal Gonadotropin/human Chorionic Gonadotropin) between 1962 and 1977. The purpose of this study was to search for hyperprolactinemia and prolactinomas in these women. Hyperprolactinemia was found in 75 women (21%). The prevalence of hyperprolactinemia increases with age. Asymptomatic pituitary tumors were found in 29 of 31 women evaluated (94%). Three women had macroadenomas and 26 had microadenomas. We were not able to demonstrate that the HMG-hCG treatment and the ensuing pregnancy had any long-term ill effects on the size of the tumor. These findings suggest that prolactinomas were slow growing. An active search for these tumors must be made in women treated for infertility in the past.

The cumulative pregnancy rate after gonadotropin treatment was evaluated in 63 hyperprolactinemic and 242 normoprolactinemic women. All pregnancies in the hyperprolactinemic patients were achieved within four treatment cycles; the cumulative pregnancy was 62% as compared with 29% in normoprolactinemics. The same results were obtained when patients were divided according to endogenous estrogenic activity. These results imply that in bromocriptine failures there is no need to lower prolactin levels to achieve pregnancy with gonadotropins.

Using special techniques the authors have analyzed the chromosome constitution of human gametes participating in fertilization in vitro. Only oocytes with multiple pronuclei have been used in this study. Two conclusions are reached by the Authors: first, that the gametes involved in the production of oocytes with multiple pronuclei can be chromosomally abnormal, specifically aneuploid and that not all oocytes with three pronuclei will cleave to form triploid embryos. The Authors underline that even normal, normospermically fertilized oocytes could have a chromosomal abnormality. They conclude that embryos with chromosomal abnormalities may be produced by IVF and ET and that their existence is reflected by the inability of the vast majority of transferred embryos to survive to term delivery.

Intra-amniotic thyroxine has been used for the induction of fetal lung maturity. The long term effects of this therapy was evaluated in a group of eighteen preschool children, 5 to 6 years of age, whose mothers received intra-amniotic thyroxine during the last trimester of their gestation. Eleven children born during the same time period were selected as controls. The children were all clinically well with no evidence of growth or endocrine abnormalities. Neurological assessment was normal and psychomotor development was in the normal range for our population and did not differ from the control subjects. Intra-amniotic thyroxine administered during the last trimester of gestation did not appear to have any significant long term detrimental effects in the treated patients.

The incidence of ectopic pregnancy is increasing throughout the Western world; at present it is uncertain how much of this increase is due to the disease and/or its antecedents and how much due to better means of diagnosis. That the treatment of the obvious or ruptured ectopic pregnancy should be surgical is beyond doubt. However, in view of the natural tendency of some ectopic pregnancies to terminate in tubal abortion or complete resorption, it is questionable whether surgery is always necessary in every early case or whether some patients can be monitored by means of rising or falling levels of beta subunits of human chorionic gonadotropin (HCG) until tubal abortion or resorption occurs. This may be the best means of preserving tubal function and fertility.

Vasa previa is an extremely rare condition. Consequently it is not often considered in the differential diagnosis of antepartum or intrapartum hemorrhage. Rupture of a fetal vessel may lead to sudden fetal death from exsanguination; therefore, this condition should be suspected in any antepartum or intrapartum hemorrhage. The blood that is lost should be tested for the presence of fetal hemoglobin. Other diagnostic tests to assess the degree of fetal distress are described. Four patients showing unusual presentations of vasa previa are reported. These cases demonstrate that fetal vessel rupture may occur independently of membrane rupture.

The diagnosis of cystic fibrosis in utero is based on amniotic fluid analysis. False negative results of this method underline the importance of antenatal ultrasonography to detect intestinal obstruction in affected fetuses.