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The purpose of this study is to evaluate the effect of uterine contractions during labor on both the uterine and the umbilical circulations. Twenty-seven patients in active labor were studied by continuous-wave Doppler velocimetry. Umbilical, left uterine, and right uterine arterial waveforms were obtained before, during, and after peak uterine contractions, and the ratio of maximum systolic and minimum diastolic velocities was calculated. Fifteen patients showed absent flow in end diastole on the uterine artery waveform and had significantly higher intra-amniotic pressures (64.5 +/- 3.5 mm Hg) during the peak amplitude of the uterine contraction compared with the 12 patients with maintained end diastolic flow (46.5 +/- 2.6 mm Hg; p less than 0.05). During the peak amplitude of the uterine contractions the 12 patients maintaining end-diastolic flow had significantly higher systolic/diastolic ratios in the uterine artery (6.5 +/- 1.5) compared with either before or after a contraction (2.1 +/- 0.15 and 2.0 +/- 0.2, respectively; p less than 0.05). Also, these 12 patients showed a linear relationship between the systolic/diastolic ratio and the intrauterine pressure. However, no differences were observed in the umbilical artery systolic/diastolic ratios before, during, or after a contraction in the intensity range studied. On the contrary, during contractions an increase in uterine artery resistance occurs with decreased or absent end-diastolic flow, which bears an inverse linear relationship to the intensity of the contraction. This suggests that during uterine contractions the human fetus continues to have uninterrupted fetoplacental blood flow, whereas the degree of interruption or reduction in uteroplacental blood flow is dependent on the intensity of uterine contraction.

Fetal echocardiography was used to identify a cardiac rhabdomyoma in the second trimester. The combination of this finding with a maternal history of Tuberous Sclerosis allowed the patient and her family to make a more educated decision regarding termination of the pregnancy. Post mortem examination of the fetus confirmed the prenatal findings. This case report demonstrates the importance of ultrasound evaluation of the fetus at risk of recurrence of a genetic syndrome in which one or more anatomical defects might be seen.

Fifty-eight fetuses were studied with use of diagnostic real-time and M-mode ultrasound between 15 and 40 weeks of gestation in which the chest circumference, biventricular outer dimension of the heart, biparietal diameter, head circumference, abdominal circumference, and femur length were measured. The chest circumference correlated with the biparietal diameter (r = 0.978), head circumference (r = 0.977), abdominal circumference (r = 0.989), femur length (r = 0.983), and biventricular outer dimension (r = 0.972). Regression analysis with predicted mean and 95% and 5% confidence limits demonstrated a linear relationship between the chest circumference and the following: biparietal diameter, head circumference, abdominal circumference, femur length, and biventricular outer dimension. Four representative cases (triploidy [69,XXX], osteogenesis imperfecta, intrauterine growth retardation, and renal agenesis) illustrate the usefulness of the data when thoracic hypoplasia is suspected.

As the result of auscultation of fetal bradycardia in a class C diabetic, real-time and M-mode echocardiography were performed at 14 weeks of gestation. M-mode evaluation revealed fetal bradycardia (70 beats per minute) with atrial and ventricular systole occurring simultaneously, suggesting a nodal rhythm. Real-time examination demonstrated a ventricular septal defect, pericardial effusion, ventricular wall hypertrophy, and a dilated aortic root. Also present were fetal ascites and situs inversus of the stomach. A repeat ultrasound examination revealed fetal death at 16 weeks of gestation. Autopsy confirmed the above structural abnormalities, and also demonstrated bilobed lungs, pulmonary artery and valve hypoplasia, midline small intestine, and asplenia.

Systolic/diastolic ratios of umbilical velocimetry obtained with either continuous-wave or pulsed-wave Doppler ultrasonography have been used to assess downstream placental vascular resistance and fetal well-being. The purpose of this study is to compare the efficacy of systolic/diastolic ratios obtained by continuous-wave and pulsed-wave Doppler ultrasonography in the prediction of poor pregnancy outcome. Continuous-wave and pulsed-wave umbilical velocimetry was performed and systolic/diastolic ratios were measured in 200 high-risk pregnancies in the third trimester by use of Angioscan III and a General Electric RT 3600 scanner, respectively. A total of 165 study participants had normal systolic/diastolic ratios and 35 participants had elevated ratios (greater than 3.0) with both continuous-wave and pulsed-wave Doppler ultrasonography. Both methods identified 35 participants with abnormal ratios, and none of the women was misclassified by either method. The pulsed-wave and continuous-wave values for 35 participants with elevated ratios were 6.35 +/- 1.52 and 6.23 +/- 1.58, respectively; values for 165 participants with normal ratios were 1.95 +/- 0.40 and 1.96 +/- 0.41, respectively (not significantly different). Participants with elevated systolic/diastolic ratios within 7 days of delivery had significantly higher incidence of adverse pregnancy outcome as judged by small-for-gestational-age fetuses, presence of meconium at delivery, fetal distress in labor, cesarean sections and 5-minute Apgar scores less than 7. Fetuses with elevated ratios were delivered at an earlier gestational age (34 +/- 1.2 weeks), had lower birth weights (1422 +/- 151 gm), and spent more time in the neonatal intensive care unit (17.1 +/- 5.2 days), compared with fetuses with normal ratios (delivered at 38.5 weeks +/- 0.9 weeks, 3100 +/- 210 gm birth weights, and 2 +/- 0.2 days spent in neonatal intensive care units, respectively, p less than 0.05). We therefore conclude that continuous-wave and pulsed-wave Doppler ultrasonography produce similar results with regard to systolic/diastolic ratios in high-risk pregnancies, and either method appears to be a valuable adjunct in the surveillance of high-risk pregnancies.

Over a two-year period, cysts of the fetal choroid plexus were diagnosed prospectively by routine second-trimester ultrasonography in five patients, representing 0.18% of the population scanned for standard obstetric indications. Gestational age at the time of diagnosis ranged from 16-22 weeks. The cysts were located in the posterior portion of the choroid plexus within the lateral ventricle. The maximum diameter ranged from 3-14 mm. In two cases, the cyst was noted to be bilocular. No additional anomalies were detected in any fetus. Follow-up sonography two to five weeks after the initial scan documented disappearance of the cysts in all cases. The course of pregnancy in these patients was otherwise uneventful, and all infants were normal physically and neurologically both at the time of birth and between four and 24 months of follow-up.

Dysfunctional uterine bleeding results from disruption of the normal sequence of ovarian cyclic hormonal stimulation of the uterine endometrium. Treatment of dysfunctional uterine bleeding previously consisted of surgical or hormonal manipulation, or both. The present study was conducted on 34 patients in a randomized double-blind fashion to evaluate the efficacy of treating dysfunctional uterine bleeding with intravenous Premarin. Bleeding stopped in 72% of patients who received intravenous Premarin and in 38% who received placebo (P = .021). Premarin was effective in terminating endometrial bleeding in patients with biopsy-proved pathology consisting of secretory, proliferative, menstrual, polypoid, or cystic hyperplasia, as well as endometritis.

Fertility in cases of Turner's syndrome is rare. In cases where conception does occur, spontaneous abortion and structural and chromosomal defects commonly are discovered. A review of the literature and a case report are presented in which pregnancy was complicated by severe intrauterine growth retardation and musculoskeletal deformities of the fetus.

The benefits of fetal intraventricular amniotic shunt remain unknown. Nevertheless, the use of this technique has been described by several authors. One of the potential complications arising from its placement is the inability to retract the catheter once it is placed through the large needle. This communication describes a modification of the shunt procedure. A suture placed through the distal end of the catheter allows retrieval of the catheter shunt for as long as the needle remains in place.

The diagnostic value of hysterosalpingography remains unquestioned. Previous studies have suggested that patients who underwent hysterosalpingography with an oil-soluble contract medium (OSCM) rather than a water-soluble contrast medium (WSCM) had higher subsequent fertility rates. This study evaluated subsequent fertility rates in 339 patients who underwent hysterosalpingography in which OSCM or WSCM was used. All forms of infertility were included and over-all, pregnancy occurred in the WSCM group in 21 of 162 patients (13%), in the OSCM group in 51 of 177 patients (29%); these rates were significantly different (P less than 0.001), with the unexplained infertility group and the male factor infertility group showing the most significant difference. Adverse effects of OSCM hysterosalpingography were not corroborated. For this reason it is suggested that initially the patient undergo hysterosalpingography with WSCM. Once patency has been established, 3 ml of OSCM should be injected as a therapeutic modality to increase subsequent fertility.

Eleven cases of major congenital anomalies were diagnosed in conjunction with arrest of dilatation or descent. In three cases, the diagnosis of fetal death was made. In the remainder, despite extensive counseling, the mothers refused cesarean section for an anomalous fetus. Fetal decompression resulted in prompt vaginal delivery in 10 of 11 cases.

With current ultrasound technology, it is now possible to obtain accurate real-time and M-mode information from the fetal heart with the use of real-time--directed M-mode echocardiography. With this method, the M-mode cursor is directed to the fetal cardiac structures of interest while the image is obtained in the real-time mode. This enables M-mode echocardiograms to be obtained in an accurate, reproducible manner. The most useful imaging planes for cardiac evaluation are the long axis four-chamber plane, the short axis plane through the atrioventricular valves, and the short axis plane through the aortic and pulmonic outflow tracts. Once normal fetal cardiac anatomy is understood, structural defects and/or alterations of function can be evaluated accurately antenatally.

With the widespread use of diagnostic ultrasound to evaluate the human fetus, it is now possible to diagnose a number of anomalies of varying organ systems. Although most anomalies of the central nervous, gastrointestinal, genitourinary, and skeletal systems are recognizable at birth, serious ones involving the cardiovascular system are often silent until the neonate demonstrates signs of cardiovascular compromise. Because an ever increasing number of fetuses are routinely scanned during pregnancy, it becomes imperative to incorporate a simple, logical approach to screen for cardiovascular disease during each fetal examination. The approach outlined in this paper would suggest that one method is the routine examination of the four-chamber view. Although there are a number of fetal and maternal risk factors which predispose to congenital heart disease, we have diagnosed a number of anomalies simply on the basis of the "screening" four-chamber examination in the "low-risk" fetus. For this reason, an attempt to examine the four-chamber view of the fetal heart should be done during each routine fetal examination. If an abnormality is noted, then a Level II, or consultative echocardiographic examination should be carried out. If a fetus at risk for congenital heart disease is being examined, a complete examination of the cardiovascular system (Levels I and II) should be performed. If the above approaches are integrated into obstetrical scanning, in the not too distant future it will be commonplace to diagnose cardiovascular anomalies prior to birth and thus provide the best care during the transition from the intrauterine to the extrauterine environment for the potentially cardiovascularly compromised neonate. The experience gained in our laboratory during the past 5 years strongly suggests that what is "today's research will become tomorrow's clinical tool."

A technique that makes use of real-time-directed M-mode echocardiography is described in which the fetal heart is evaluated for suspected cardiac arrhythmias. Simultaneous M-mode recording of aortic, mitral, or tricuspid valvular leaflet excursion and/or atrioventricular wall motion defines timing relationships between atrial and ventricular systole. With the use of the techniques described in this report, normal as well as abnormal atrioventricular contractions can be quantitated and cardiac arrhythmias accurately defined.

Umbilical and uterine artery velocimetry was performed using continuous-wave Doppler ultrasound (Angioscan III) in 60 patients in preterm labor. Peak-systolic/end-diastolic ratios were calculated according to previously described techniques. All measurements were made before tocolytic therapy was begun: magnesium sulfate (n = 40) or ritodrine (n = 20). The mean gestational age was 33.1 +/- 1.5 weeks (range 29 to 36 weeks). Twelve (20%) patients had elevated (greater than 2.6) pretherapy uterine peak-systolic/end-diastolic ratios, 10 (16.7%) patients had elevated (greater than 3.5) pretherapy umbilical peak-systolic/end-diastolic ratios, and in eight (13.3%) patients both ratios were elevated. In seven (58.4%) of the 12 patients with elevated uterine peak-systolic/end-diastolic ratios, six (60%) of the 10 patients with elevated umbilical peak-systolic/end-diastolic ratios, and five (62.5%) of the eight patients with both ratios elevated tocolytics failed and the women were delivered within 48 hours, compared with seven (14.6%) of 48, eight (16%) of 50, and six (13.0%) of 46 with normal ratios, respectively (p less than 0.05). We conclude that patients in preterm labor with elevated pretherapy uterine and/or umbilical peak-systolic/end-diastolic ratios are more likely to fail tocolysis therapy and be delivered preterm than those with normal ratios. It may therefore be useful to include umbilical and uterine velocimetry in the initial evaluation of preterm labor.

The effect of tocolytics on systolic to diastolic (S/D) ratios used to assess downstream vascular resistance and obtained from umbilical and uterine velocity waveforms has not been studied to date. Continuous-wave Doppler studies were performed on the umbilical and uterine arteries of 60 consecutive patients with the diagnosis of preterm labor. Forty patients receiving intravenous magnesium sulfate and 20 patients receiving intravenous ritodrine tocolysis underwent Doppler studies before therapy, during incremental therapy, and four hours post-therapy. There was a statistically significant (P less than .001) progressive decrease in the uterine and umbilical S/D ratios along with a concomitant increase in maternal and fetal heart rate associated with increasing infusion doses of ritodrine. Both the S/D ratios and heart rates returned to pretherapy range four hours after discontinuing therapy. Magnesium sulfate tocolysis was not associated with any significant change in S/D ratios or maternal and fetal heart rate. We conclude that intravenous ritodrine affects umbilical and uterine vascular resistance as measured by S/D ratios. This response may be secondary to changes in maternal and fetal heart rate.

The aortic root dimension and aortic valve excursion of 43 normal fetuses were recorded with M-mode echocardiography and the measured dimensions correlated with noncardiac measurements (biparietal diameter, head circumference, abdominal circumference, and femur length) and cardiac measurements (diastolic biventricular inner dimension, diastolic left ventricular internal dimension, and mitral valve excursion). The correlation coefficients for the aortic root dimension ranged between 0.87 and 0.95, while those for the aortic valve excursion ranged between 0.78 and 0.87. Regression analysis demonstrated that the best fit of the data was a linear model from which the 5% and 95% confidence limits were computed for individual predictions of aortic root dimension and aortic valve excursion from noncardiac and cardiac measurements.

The estimation of weight in the very low-birth weight fetus (less than 1500 gm) is becoming more important in obstetric management as neonatal nurseries are reporting better outcome in this weight category. It has become clear that assessment of weight can best be accomplished through the use of ultrasound. In many institutions, however, ultrasonography is under the control of other departments and is not readily available. This arrangement prevents rapid access and compromises the benefit of the technique. To evaluate the accuracy of scans performed in very low-birth weight infants by personnel with limited training in ultrasonography, we undertook a systematic study of weight estimates in this select group of patients. To date, 31 ultrasound examinations have been performed by staff physicians and 50 by resident physicians. Comparisons made between ultrasound examinations by staff and resident physicians showed that the absolute error between the ultrasound-predicted weight and the actual weight, though less in the case of staff physician examinations, was not statistically significant.

Systolic to diastolic (S/D) ratios of umbilical velocimetry using either continuous-wave or pulsed-wave Doppler ultrasound have been used to assess downstream placental resistance. The purpose of this study was to compare the S/D ratios obtained by both types of instrumentation to determine whether there are significant differences between measurement values. Umbilical velocimetry was performed on 200 high-risk pregnancies in the third trimester using the Angioscan III to obtain continuous-wave velocimetry and the General Electric RT3600 to obtain pulsed-wave velocimetry. Systolic to diastolic ratios were considered abnormally high if they were greater than 3. One hundred sixty-five patients had normal S/D ratios and 35 patients had elevated ratios on both continuous-wave and pulsed-wave ultrasound. There was no significant difference in the mean S/D ratios obtained by either method for the entire population (continuous-wave S/D 2.81 +/- 1.79, pulsed-wave S/D 2.71 +/- 1.83, R = 0.98), the normal group (continuous-wave S/D 1.96 +/- 0.41, pulsed-wave S/D 1.95 +/- 0.40, R = 0.91), and the abnormal group (continuous-wave S/D 6.23 +/- 1.58, pulsed-wave S/D 6.35 +/- 1.52, R = 0.94). Least-square regression was performed to model the relationships between pulsed wave and continuous wave, with both used as dependent variables. The slopes and intercept for the normal and abnormal groups were evaluated and were significantly different (P less than .01).(ABSTRACT TRUNCATED AT 250 WORDS)

Sixty-three patients with antenatally diagnosed fetal malformations over the period of 14 months were prospectively offered genetic amniocentesis, irrespective of gestational age. An additional 15 patients were excluded from the study because of a known lethal malformation (13 anencephaly, two amniotic bands). Twenty patients accepted amniocentesis, and seven chromosomal disorders were found. Obstetric management was altered in some of these patients as a result of the anomalies.

Given the current widespread use of diagnostic ultrasound, it is important to identify exactly what information is desirable during the examination. Although dating the pregnancy might be the reason for the initial evaluation, it is important to examine the fetus for structural malformations as well. Both can be accomplished with a second-trimester scan. Once the pregnancy is accurately dated, subsequent measurements of the head, abdomen, and femur should be plotted on growth curves in relation to the age of the fetus, based on the earlier ultrasound examination. The patient should not be related with subsequent examinations. If asymmetric growth failure occurs, then intervention or maternal bed rest should be considered. Intervention should be considered in the presence of abnormal antepartum testing and when fetal growth has arrested following the institution of maternal bed rest. If symmetric IUGR is present, careful evaluation of the fetus for structural malformations and an abnormal karyotype should be considered.