Search

Eighty-two consecutive fetuses with ultrasound evidence of isolated pyelectasis (defined as dilatation in the anteroposterior renal pelvic dimension of ≥ 4 mm) were prospectively followed to determine the risk for postnatal uropathy and Down syndrome. In 98 (60%) kidneys, isolated pyelectasis was shown to be the first manifestation of a pathophysiological process that evolved into a gamut of postnatal uropathies (defined as urological conditions requiring remedial surgery or extended medical surveillance). Data quantifying the risk for postnatal uropathy in fetuses with varying degrees of isolated pyelectasis, at different gestational ages, are presented in figure format to facilitate prenatal counselling. Bivariate analysis showed that the evolution of isolated pyelectasis to uropathy was statistically significant when in utero progression was noted or in conjunction with other findings including contralateral pyelectasis (p < 0.01), male gender (p < 0.01) and increased kidney length (p < 0.001). Importantly, 55% of the infants requiring corrective surgery demonstrated in utero progression of pyelectasis (p < 0.002). Serial ultrasound examinations were necessary to evaluate progression or regression in the extent of pyelectasis. Finally, isolated pyelectasis was associated with an increased risk for Down syndrome, beginning at maternal age of 31 years, in the interval of 16–20 weeks' gestation. Copyright © 1996 International Society of Ultrasound in Obstetrics and Gynecology

Objective : To determine the incidence of chromosomal abnormalities among fetuses with isolated pyelectasis. Methods : Between March 1991 and March 1994, 121 cases of isolated fetal pyelectasis were identified at our institution. Pyelectasis was defined as a renal pelvis anteroposterior diameter of at least 4 mm before 33 weeks' gestation, and at least 7 mm at 33 weeks or thereafter. Once identified, women were offered antenatal genetic testing; if they declined, consent was sought for umbilical cord blood studies at delivery. Results : Chromosomal evaluation was available in 99 women. Two chromosomal abnormalities were identified: one trisomy 21 and one mosaic 46,XY/47,XYY. The ages of the women were 32 and 28 years, respectively. Calculation of adjusted risks for Down syndrome and all chromosomal abnormalities indicated a 3.9-fold increase in Down syndrome risk and a 3.3-fold increase in risk for all chromosomal abnormalities in the presence of isolated fetal pyelectasis. Conclusion : Isolated fetal pyelectasis is associated with increased risk, over that related to age, for both Down syndrome and all chromosomal abnormalities. These factors may be valuable in counseling individual patients regarding the appropriateness of amniocentesis.

We investigated the participation of the cellular arm of the immune system in adaptation to pregnancy by assessing plasma and amniotic fluid levels of the cytokine tumor necrosis factor-alpha.Fifty-five healthy pregnant women who underwent second-trimester genetic amniocentesis at a mean gestational age of 17.0 +/- 1.4 weeks composed study group A. Blood was drawn from each patient before amniocentesis, and an aliquot of amniotic fluid was obtained for this study. Twenty-one healthy patients at a mean gestational age of 35.5 +/- 4.8 weeks composed study group B, and blood was obtained from each patient at an outpatient prenatal visit. Twenty-two healthy, nonpregnant women of reproductive age composed the control group (C). All specimens were stored at -70 degrees C and collectively assayed for tumor necrosis factor-alpha by a specific enzyme-linked immunoassay.All patients in group A had a normal karyotype and all patients in groups A and B had uneventful pregnancies. Tumor necrosis factor-alpha was detected in the plasma of 43 of 55 (78.2%) patients in group A compared with 7 of 21 (33.3%) patients in group B (p0.001); tumor necrosis factor-alpha was not detected in any of the 22 women in group C. The median plasma tumor necrosis factor-alpha level for group A was 135 pg/ml (range 0 to 625 pg/ml) compared with 0 pg/ml (range 0 to 110 pg/ml) in group B (p0.001). Tumor necrosis factor-alpha was not detected in any of the amniotic fluid specimens studied.Levels of tumor necrosis factor-alpha were elevated in the plasma but not detected in the amniotic fluid of normal pregnant patients in the second trimester. These findings suggest involvement of the cellular branch of the immune system and its products, the cytokines, in the normal adaptation of the mother to the fetal allograft, with a possible role in regulating trophoblast growth and invasion.

Objective: Our purpose was to prospectively evaluate the risk of chromosomal abnormalities associated with isolated choroid plexus cyst(s) in gravid women undergoing second-trimester ultrasonographic examination. Study Design: During a 24-month period 9100 pregnant women underwent midtrimester ultrasonographic evaluation. Women with a fetal diagnosis of choroid plexus cyst(s) were offered amniocentesis and a repeat examination in 4 to 6 weeks. Results: A diagnosis of choroid plexus cyst(s) was made in 102 fetuses (1.1 %). In four of these fetuses multiple congenital anomalies were noted. Three of the four fetuses had a chromosomal abnormality, two trisomy 18 and one unbalanced translocation, t(3;13). In the remaining 98 fetuses the choroid plexus cysts were isolated findings, that is, there were no other ultrasonographically detected anomalies. Seventy-five of these 98 fetuses underwent amniocentesis. An abnormal karyotype was identified in four fetuses: three had Down syndrome (two trisomy 21 and one unbalanced translocation, t[14;211), and one trisomy 18. The offspring of,the 23 patients in which amniocentesis was declined were phenotypically normal. Conclusions: In our prospective study the risk of chromosomal abnormality with isolated choroid plexus cyst(s) was 1:25, a risk that exceeds the 1:200 risk of pregnancy loss after amniocentesis and the 1:126 and 1:260 risk for aneuploidy and Down syndrome, respectively, in a 35-year-old pregnant women during the midtrimester. These findings indicate that amniocentesis should be offered to pregnant women in the presence of isolated fetal choroid plexus cyst(s).

Objective: Our purpose was to determine the incidence of significant neonatal morbidity in fetuses with documented pulmonary maturity delivered before 37 weeks' gestation. Study Design: A retrospective review of 213 pregnancies with documented fetal lung maturity (lecithin/sphingomyelin ratio ≥ 2.0 or phosphatidylglycerol present) and delivery before 37 weeks was performed. The incidence of neonatal respiratory distress syndrome, bronchopulmonary dysplasia, grade 3 or 4 intraventricular hemorrhage, necrotizing enterocolitis, patent ductus arteriosus, retinopathy of prematurity, infectious morbidity, hyperbilirubinemia, and admission to the special care nursery was determined for those pregnancies with intact membranes and preterm premature rupture of membranes. Results: Serious neonatal morbidity declined with advancing gestational age and was less common after 32 completed weeks of pregnancy. Although the frequencies of respiratory distress syndrome, grade 3 or 4 intraventricular hemorrhage, and necrotizing enterocolitis were 19.4% (12/62), 8.1% (5/62), and 4.8% (3/62), respectively, at ≤ 33 weeks' gestation, one case of respiratory distress syndrome, one case of grade 3 intraventricular hemorrhage, and one case of necrotizing enterocolitis occurred in the 151 neonates born at ≥ 34 weeks' gestation. Conclusions: In spite of fetal lung maturity major neonatal morbidity was observed in our patient population. These data relating neonatal morbidity to gestational age are useful in the critical decision regarding timing of delivery.

We studied longitudinal ultrasonographic growth patterns (abdominal circumference, biparietal diameter) initiated early in gestation in 52 pregnancies complicated by pregestational diabetes mellitus and 19 controls. Three predominant patterns of growth were ascertained including a heretofore unrecognized pattern characterized by accelerated abdominal circumference growth (greater than 90th percentile) before 24 weeks' gestational age. Maternal and neonatal anthropometric and metabolic parameters were contrasted for the three patterns. The findings suggest that in some cases of diabetic macrosomia that can be recognized before 24 weeks' gestation, augmented growth may be influenced by factors other than fetal hyperinsulinism.

Objective Epithelial ovarian cancer kills more women than all other gynecologic malignancies combined because of our inability to detect early-stage disease. Ultrasonography has demonstrated usefulness in the detection of ovarian cancer in asymptomatic women, but its value for the detection of early-stage epithelial ovarian cancer in women of increased risk is uncertain. We examined the usefulness of sonography in the detection of early-stage epithelial ovarian cancer in asymptomatic high-risk women who participated in the National Ovarian Cancer Early Detection Program. Study design Only asymptomatic women of increased risk for the development of ovarian cancer with initial normal gynecologic and ultrasound examinations were eligible to participate in the institutional review board–approved National Ovarian Cancer Early Detection Program. Participants underwent comprehensive gynecologic and ultrasound examinations every 6 months. Increased risk includes women with at least 1 affected first-degree relative with ovarian cancer; a personal history of breast, ovarian, or colon cancer; ≥1 affected first- and second-degree relatives with breast and or ovarian cancer; inheritance of a breast cancer mutation from an affected family member, or membership within a recognized cancer syndrome. Results The average age of the 4526 women who were evaluated was 46 years; 2610 women were premenopausal, and 1916 women were postmenopausal. A total of 12,709 scans have been performed since 1990. Visualization of both ovaries was noted in 98% of premenopausal and in 94% of postmenopausal women. Fourteen women had undergone unilateral salpingo-oophorectomy. Recall rates at less than the routine 6-month interval were 0.4% in the premenopausal and 0.3% in postmenopausal women. A total of 98 women with persistent adnexal masses were identified, and 49 invasive surgical procedures were performed that diagnosed 37 benign ovarian tumors and 12 gynecologic malignancies. All cancers were detected in asymptomatic women who had normal ultrasound and physical examinations 12 and 6 months before the cancer diagnosis. The detected malignancies were fallopian tube carcinoma (stage IIIC; n = 4 women), primary peritoneal carcinoma (n = 4 women; stage IIIA, 1 woman; stage IIIB, 2 women; stage IIIC, 1 woman), epithelial ovarian cancer (stages IIIA and IIIB; n = 2 women), and endometrial adenocarcinoma (stage IA; n = 2 women). Additionally 37 primary and 12 recurrent breast carcinomas were detected by physical examination. A total of 184 women with genetic predisposition (breast cancer positive) have undergone a prophylactic bilateral salpingo-oophorectomy; 23% of these procedures found atypical hyperplasia, and unexpectedly, 2 women (1%) were found to have stage III (A and B) primary peritoneal carcinoma. Conclusion This study demonstrates the limited value of diagnostic ultrasound examination as an independent modality for the detection of early-stage epithelial ovarian cancer in asymptomatic women who are at increased risk for disease.

Arteriovenous malformation of the uterus is a rare uterine abnormality. This entity is generally associated with the presence of molar disease, choriocarcinoma and uterine surgery, but may be congenitally acquired. The presence of an arteriovenous malformation generally leads to unexplained profuse uterine bleeding. The diagnosis of this entity has traditionally been made by arteriography, and the treatment is usually hysterectomy. We present a patient with an arteriovenous malformation of the uterus whose prior delivery was by Cesarean section. The patient experienced episodes of heavy vaginal bleeding in the first month following the procedure of suction curettage for a first-trimester pregnancy loss. Chorionic villus sampling performed prior to the procedure showed a chromosomally normal fetus. The diagnosis of an arteriovenous malformation was made by color Doppler velocimetry and confirmed with arteriography. The patient desired to maintain her fertility. Interventional radiological techniques were successfully utilized to obliterate the arteriovenous malformation with the use of polyvinyl alcohol particles (250 micro m) and gelfoam. Discussion includes the presenting signs and symptoms along with the method of both diagnosis and conservative management.

Our purpose was to investigate fetal cerebral blood flow and the incidence of intraventricular hemorrhage in patients undergoing tocolysis with either indomethacin or magnesium sulfate at30 weeks' gestation.Consenting patients at30 weeks' gestation with preterm labor were randomized to receive indomethacin or magnesium sulfate tocolysis. Magnesium sulfate was administered intravenously with an 8 gm loading dose given over the first hour, 4 gm over the second hour, and then a maintenance infusion of 2.5 gm per hour. The infusion was continued for approximately 12 hours after the cessation of uterine contractions. Patients randomized to receive indomethacin were given an initial dose of 50 to 100 mg orally or per rectum, followed by 25 to 50 mg orally every 4 to 6 hours for 24 to 48 hours. Oral tocolytic agents were not used after successful tocolysis. Betamethasone was administered to all patients. Patients underwent fetal cerebral Doppler studies during tocolytic therapy and at least 24 hours after completion of the treatment.Twelve patients were randomized to receive indomethacin and twelve patients were randomized to receive magnesium sulfate. Twenty-one fetuses underwent cerebral Doppler studies in triplicate during and after therapy. The mean gestational age at tocolysis was 27.5 +/- 1.9 weeks for the indomethacin group and 26.4 +/- 1.6 weeks for the magnesium sulfate group (p = 0.14). The middle cerebral artery resistance index for fetuses during indomethacin treatment was 0.73 +/- 0.09, whereas the resistance index after therapy was 0.75 +/- 0.05 (p = 0.49). The resistance index during magnesium sulfate tocolysis was 0.79 +/- 0.04 and after therapy it was 0.76 +/- 0.04 (p = 0.18). There was no significant difference in the resistance index between the groups on or off therapy. In addition, the incidence of intraventricular hemorrhage was similar in both groups.These results suggest that indomethacin does not significantly affect fetal cerebral blood flow. If antenatal indomethacin in the preterm fetus increases the risk of intraventricular hemorrhage, it would appear to be by another mechanism.

OBJECTIVE: The objective of this study was to determine the significance of isolated hyperechoic fetal bowel STUDY DESIGN: Forty-five cases with prospective, ultrasonographic diagnosis of isolated hyperechoic fetal bowel were reviewed. Fetal variables, including aneuploidy, deoxyribonucleic acid studies for cystic fibrosis, congenital infection, growth retardation, and intrauterine death were reported. RESULTS: Thirty-four of the 45 cases (76%) resulted in live-born infants without detected abnormalities. However, hyperechoic bowel was associated with cystic fibrosis in two cses (4%), congenital infection in two cases (4%), and fetal alcohol syndrome in one case. Termination of pregnancy was elected in three casees and intrauterine fetal death occurred in three cases (7%). Growth retardation was observed in five of 39 (13%) live-born infants. CONCLUSION: Isolated hyperechoic fetal bowel is associated with significant pathologic disorders. Women whose fetuses are diagnosed as having isolated hyperechoic bowel should be offered additional prenatal diagnostic options, including maternal serologic studies for congenital infection, fetal karyotype, and deoxyribonucleic acid testing for cystic fibrosis. In addition, continuing ultrasonographic evaluation to fetal growth and antenatal biophysical assessment should be considered.

Objective To evaluate the perinatal outcome in fetuses with single umbilical artery detected on targeted prenatal ultrasound without other anomalies. Methods During a 3.5-year period, an isolated single umbilical artery was suspected on prenatal ultrasound examination in 57 fetuses evaluated at two referral centers. Targeted imaging to rule out concurrent fetal anomalies was normal in all cases. Pregnancy and perinatal outcome data were retrieved by review of the medical records or from conversations with referring physicians. Complete follow-up was available in 50 cases. Results A two-vessel umbilical cord was confirmed at birth in 50 neonates. The mean gestational age at delivery was 38.6 ± 2.8 weeks; the mean birth weight was 3202.8 ± 835.8 g. Seventeen patients (34%) underwent genetic amnio-centesis, and all fetuses had a normal karyotype. The only neonate ascertained to have a congenital anomaly after birth was diagnosed with total anomalous pulmonary venous return. This neonate underwent a corrective surgical procedure and is thriving with no apparent problems at 3.5 years of age. There were no perinatal deaths. Conclusion In the absence of additional sonographically detectable anomalies, an isolated single umbilical artery does not seem to affect clinical outcome and therefore should not alter routine obstetric management.

In the field of obstetrics, terms such as dates, gestational age, fetal age, and fetal maturity all refer to the length of pregnancy from the first day of the last menstrual period (LMP), rather than from the time of ovulation. It is recognized that assessment of dates from LMP is fraught with errors. The reason is that LMP remains uncertain in 20 to 40% of gravidas.1

The majority of the externally visible abnormalities are included in this section and are presented in two parts. In the first part, cleft lip/ palate, cystic hygroma, nonimmune fetal hydrops, sacrococcygeal teratoma, and skeletal dysplasias are discussed. In the second part, defects of the central nervous system are described.

OBJECTIVE : We evaluated an alternative approach to the management of triplet gestations that did not include home uterine monitoring, prophylactic tocolysis, or routine antepartum hospitalization. STUDY DESIGN : Fifteen patients were managed over a 42-month period by an antepartum protocol that emphasized patient education regarding signs and symptoms of preterm labor, weekly prenatal visits after 24 weeks' gestation with cervical examination, and increased rest in an outpatient setting. Tocolytic therapy was only used for regular uterine contractions when cervical change was documented. RESULTS : Nine of 15 (60%) patients with management in this uniform manner were delivered at ≥35weeks' gestation, and six patients (40%) completed 37 weeks of pregnancy. Only five patients (33%) received tocolytic therapy. The mean birth weight was 1957 ± 488 gm, and only 19 of 45 neonates (42%) were admitted to the intensive care nursery. CONCLUSION : This management scheme was effective in reducing preterm delivery and thereby optimizing perinatal outcome. (Am J Obstet Gynecol 1992;167:1117–20.)

Maternal serum alpha-fetoprotein may be reduced in diabetic pregnancies, but the association with elevated glycosylated hemoglobin has been controversial. We tested the hypothesis that reductions in maternal serum alpha-fetoprotein may reflect the same phenomena that can also impair normal rates of embryo growth in the presence of poorly compensated maternal diabetes. If so, associations would be expected among maternal serum alpha-fetoprotein, embryo rates of growth, and levels of glycosylated hemoglobin reflective of regulation of maternal diabetes during the period of organogenesis. We found maternal serum alpha-fetoprotein levels in 93 pregnant patients with diabetes to be negatively associated with the earliest (4 to 12 weeks) glycosylated hemoglobin determinations. At glycosylated hemoglobin values greater than 9.6% (which approximates the upper quartile), all maternal serum alpha-fetoprotein values fell below the median for patients without diabetes (below 0.8 multiple of the median after weight adjustment). Moreover, there was a trend for pregnancies with lower maternal serum alpha-fetoprotein levels and higher glycosylated hemoglobin values to also demonstrate early fetal growth delay as measured by ultrasonography.

We retrospectively studied 209 patients treated with ritodrine hydrochloride to determine whether change in cervical effacement or dilatation during a period of observation before therapy would result in decreased efficacy of ritodrine, as measured by delivery delays of 48 hours, 1 week, or until greater than or equal to 37 weeks' gestation; neonatal intensive care unit admission; and neonatal respiratory distress syndrome. Patients who were greater than or equal to 3 cm dilated on admission were at high risk of therapy failure by all outcome measures compared with patients less than 3 cm dilated. For patients less than 3 cm dilated on admission, there was no difference in outcome when patients treated for contractions only were compared with those treated after change in effacement or dilatation had been documented. We conclude that awaiting change in cervical effacement or dilatation to be more certain of the diagnosis of preterm labor will not compromise the efficacy of ritodrine tocolysis.

Current antenatal technologies have improved the obstetrician's ability to assess fetal well-being as well as to diagnose fetal compromise. These technologies have given rise to very difficult ethical issues in the management of compromised twin pregnancies: for example, a choice must be made between putting a healthy twin at risk due to preterm delivery for the sake of a compromised cotwin or of allowing the compromised twin to die in order to buy time for the healthy twin. Though each case is unique, good medical practice requires a standard of care by which consistent patient management can be proposed. In the pluralistic environment of Northwestern Memorial Hospital, our staff has favored a standard of care based on patient autonomy. This approach demands: 1) a practitioner who offers a thorough explanation of the diagnosis and possible treatment approaches; 2) time for the patient and her partner to assimilate this information and test treatment options against their personal value system; 3) a third, but disinterested, party to facilitate patient understanding and value clarification; 4) a practitioner either willing to support the patient's decisions or refer her to another practitioner who will.

The association of parvovirus B19 infection and hydrops fetalis is well known. However, the association of parvovirus and fetal pleural or pericardial effusions has not been reported. We present five cases of isolated pleural or pericardial effusion with documented maternal parvovirus infection in four of these pregnancies. In the absence of structural or karyotypic abnormalities, spontaneous resolution of the effusion portends for a successful pregnancy outcome.

Ultrasound is assuming an essential role in the detection of fetal cranial and spinal anomalies. Illustrated in this article is the sonographic appearance of cranial abnormalities wherein the diagnosis of encephalocele is clear cut because the anatomic defect of the neural tube is visualized. Additionally presented is a variety of cranial and craniocervical cystic masses, including meningocele, wherein the anatomic defect of the neural tube is not apparent and the diagnosis is reached by careful attention to the specific ultrasonic characteristics of each mass.

Data from previous studies have suggested that birth weight prediction was enhanced by using formulas specifically derived from preterm fetuses. However, no prospective comparison of different formulas was performed. We obtained ultrasonic data on 61 pregnancies at risk for preterm delivery with a gestational age of 29.0 +/- 3.0 weeks (mean +/- SD). In all women birth weight was predicted within 7 days of delivery. Of the 61 pregnancies, 49 (80%), 41 (67%), 30 (49%), and 17 (28%) weighed less than 1750, 1500, 1250, and 1000 gm, respectively; 14 published formulas were compared for accuracy in predicting birth weight in these four categories. The formulas with the smallest absolute mean percent errors incorporated head and abdominal circumferences and femur length. The formula of Weiner et al., derived from low birth weight infants, produced the smallest absolute mean percent error and SD, 10.9% +/- 7.9%; this error was further reduced to 7.7% +/- 6.5% in infants weighing less than 750 gm. These findings suggest that birth weight in the preterm fetus is best predicted by a formula targeted to such a population.

Cytologic findings of amniotic fluid material (AFM) in pulmonary arterial blood (PAB) of survivors of amniotic fluid embolism (AFE) are assumed to be pathologic. However, no cytologic studies of central blood from patients without clinical AFE have been reported. To address this question PAB samples from peripartum patients without clinical AFE were examined for the presence and extent of AFM (including squames, mucin, and lanugo hair). Ten samples were obtained from five patients. All patients had at least one sample postpartum. Peripheral blood from a nonpregnant adult female control was processed similarly. Results were compared to a PAB sample from a patient with clinical AFE. The patient with clinical AFE had many squames, clumps of lanugo hair, and mucin in one sample. In six of ten study samples, there were squames, accompanied in two cases by lanugo hair or trophoblast. In nine of ten samples there was mucin. There appeared to be no difference in cytologic findings in patients according to mode of delivery or sampling time. The control blood sample was negative for amniotic fluid-like material. AFM may be found in peripartum patients without clinical amniotic fluid embolism. A quantitative difference was seen between the index patient and each of our five study patients. These findings suggest that there is a quantitative continuum of AFM transported to the central circulation in peripartum patients which may, in part, explain the varied clinical presentations and severity of AFE.

Expectant management of prolonged pregnancy is predicated on reassuring biophysical testing. However, even the combination of a reactive nonstress test and normal amniotic fluid volume may not prevent subsequent morbidity. To test the hypothesis that diminished cord Wharton's jelly incurs risk of peripartum cord compression in addition to decreased amniotic fluid, 68 patients with confirmed gestational age greater than or equal to 41 weeks were evaluated prospectively with semiweekly nonstress tests and weekly ultrasound examinations. Amniotic fluid volume was assessed, and umbilical cord diameter was measured and then correlated with the quantity of Wharton's jelly at delivery, determined by cord circumference. A significant correlation between cord circumference and umbilical cord diameter was observed, even in those patients with decreased amniotic fluid volume. Either an amniotic fluid volume less than 3.8 cm or an umbilical cord diameter less than 1.6 cm was associated with significant cord compression patterns. Peripartum morbidity was greatest in the presence of a smaller cord and decreased fluid, suggesting a synergism between these two factors for the risk of cord compression in prolonged pregnancy.

Intrapartum events were studied in 272 patients with meconium-stained amniotic fluid. All infants underwent DeLee suction followed by intubation and 58 of 272 had meconium present below the vocal cords at delivery. Neither the total duration of variable fetal heart rate decelerations or a continuous saltatory pattern nor the presence or absence of late decelerations could be related to an increased risk of meconium below the vocal cords. When a rising baseline fetal heart rate and decreased variability were present as well, a significantly greater proportion of patients had meconium below the vocal cords. Routine obstetric and pediatric suctioning did not prevent the single death that occurred in a fetus who had deep meconium aspiration in utero.

Six subjects with distal ampullary ectopic pregnancies were treated with four doses of intravenous methotrexate (1.0 mg/kg) followed by four doses of leucovorin (0.1 mg/kg, intramuscularly). The diagnosis was established in all cases by laparoscopy following sonography and radioimmunoassay for serum beta subunit of human chorionic gonadotropin. Subjects were followed with daily quantitative serum beta-human chorionic gonadotropin radioimmunoassay and sonography. Five of the six subjects experienced resolution of their ectopic pregnancy without additional surgical treatment. One subject underwent salpingectomy following treatment. Morbidity also included three patients with mild stomatitis or gastritis, and two patients had transient elevations of serum transaminase levels. Two patients had protracted courses and received blood transfusions. The most abrupt response and most uncomplicated courses were experienced in the three subjects with initial human chorionic gonadotropin levels below 1000 mIU/ml. This preliminary experience suggests that methotrexate may be an effective alternative for the treatment of early ectopic pregnancy.

Previous studies have demonstrated diminished ultrasonic fetal growth parameters in women delivering preterm. In this study, we tested the following hypothesis: In pregnancies complicated by spontaneous preterm labor, 1) unsuccessful tocolysis is likely to be associated with diminished fetal growth, and 2) successful tocolysis is likely to occur when fetal growth is normal. Ultrasound examinations were performed in 78 pregnancies complicated by preterm labor before 35 weeks' gestation. Tocolysis was attempted unless contraindicated or unless cervical dilatation was advanced (4 cm or greater). Pregnancies delivering before 36 weeks' gestation were compared with those delivering after this gestational age. Among the 48 pregnancies delivered before 36 weeks' gestation, a significantly greater proportion had ultrasonic growth parameters lower than normal values at corresponding gestational ages. In contrast, those pregnancies that had successful tocolysis and delivered near term demonstrated a normal distribution of ultrasound growth parameters. In pregnancies complicated by preterm labor, ultrasonic documentation of diminished fetal growth may identify the subgroup at increased risk for preterm delivery.

We present the percentile ranks of sonar fetal abdominal circumference (AC) measurements from 18 to 41 weeks' gestation. The ACs are derived from both longitudinal and cross-sectional ultrasonic studies of 200 low-risk pregnant women. The reproducibility of sonar AC falls within 2% of the mean value; this variation permits antenatal distinction of the fetus with a small AC (less than twenty-fifth percentile) or large (greater than eightieth percentile) reading. The fetal AC measurements add another dimension to the interpretation of cephalic growth, particularly in identifying macrosomic fetuses as well as those who are either asymmetrically or symmetrically undergrown. Additionally fetal AC measurements are useful as adjuncts to the diagnosis of hydrocephalus by quantitating the difference between cephalic and body size. In the presence of fetal ascites the AC also can be used to assess the severity and progression of the abnormality.

To test the applicability of equations for fetal weight estimations in a group of fetuses suspected of being large for gestational age, real-time ultrasound measurements of fetal biparietal diameters and abdominal circumferences were obtained for 34 fetuses of diabetic mothers. In the first phase of the study the accuracy in the prediction of weight was assessed with use of two known equations. In the second phase, biparietal diameter, abdominal circumference, and actual birth weight data of the 34 study fetuses were used as independent variables to determine the best-fitting equation for relating estimated fetal weight (EFW) to biparietal diameter (BPD) and abdominal circumference (AC); this equation is log (EFW) = 0.02597 AC + 0.2161 BPD - 0.1999 (AC X BPD2)/1000 + 1.2659. The standard deviation of differences is 322.26 gm and multiple R = 0.781. In the final phase the reliability of this equation was compared to those of Thurnau and Shepard in 34 additional fetuses of diabetic gravid women. The data suggest that in these fetuses suspected of being large for gestational age the weight estimates calculated at or near term may be enhanced if predictive equations are formulated specifically from the data for such fetuses.

Forty pregnancies in 37 women who were previously delivered of a live-born fetus between 20 and 32 weeks' gestation are reported here. Fourteen pregnancies were treated with cervical cerclage between 14 and 16 weeks. Twenty-six pregnancies were initially managed conservatively, but three of these patients had a McDonald cerclage placed between 18 and 23 weeks because of significant change in cervical effacement or dilatation. The risk of preterm delivery was 36% (5 of 14) in the cerclage group and 38% (10 of 26) in those patients managed conservatively. The perinatal survival rates were 93% (13 of 14) and 88% (23 of 26), respectively. These results are encouraging when it is considered that only 14% (9 of 64) of prior gestations (exclusive of spontaneous abortions and elective terminations) were carried to term and the perinatal survival rate was 28% (18 of 64). Although this study was nonrandom, these results also support the selective use of cervical cerclage on the basis of past history and physical examination.

We examined biparietal diameter, abdominal circumference, and birth weight in 148 preterm infants to assess fetal growth. A statistically significant proportion of preterm fetuses had biparietal diameter and abdominal circumference values below the fiftieth and tenth percentile levels as compared with that expected in normal fetuses. Similarly, birth weight of infants in the study fell significantly below the fiftieth and tenth percentiles relative to Brenner's curve. We corclude that diminished fetal growth is associated with early delivery secondary to preterm labor or preterm premature rupture of membranes or both. Additionally, since biparietal diameters in preterm fetuses are smaller than those of normal fetuses the prediction of gestational age by cephalometry should be advanced by 7 to 10 days.

The diagnosis of fetal hydrocephalus based on dilation of the ventricular system presents a broad range of management decisions. The options are presented and a case of Dandy-Walker syndrome managed by fetal ventriculoamniotic shunt placement is presented as an example. Under ultrasonic guidance, a shunt was placed at 30 weeks' gestation by later newborn Dubowitz examination. Delivery was delayed for five weeks, one to two weeks following probable shunt malfunction, after achieving fetal lung maturation. Follow-up six months after definitive neonatal ventricular shunting and three weeks after shunt revision revealed a socially active male infant with a motor development index of 87 and a psychomotor development index of 95. Potential advantages of fetal surgery including achievement of term gestation are presented. Proposed guidelines for determining the benefit of such procedures are also presented.

The ultrasonic abdominal circumference (AC) measurement is one of the essential parameters used for assessment of fetal status. Whereas the AC was traditionally derived by static equipment, dynamic scanners are presently used for that purpose. In this study, the AC values obtained by two gray-scale ultrasonic imaging modalities (static and dynamic) were compared; the differences between the mean AC measurements were not statistically significant. Additionally, when the outline of the AC in a fetus near term was larger than the sonic field displayed by dynamic equipment, the partially incomplete boundary could be “filled in” without affecting the accuracy of the result.

This report sought to determine whether estimates of fetal weight are enhanced by using ultrasonographic formulas targeted to the large-, appropriate-, and small-for-gestational-age fetus in both preterm and term pregnancies. Ultrasonographic fetal measurements from 575 singleton pregnancies were obtained within 7 days of delivery. The first 194 fetuses were classified into three groups on the basis of the growth percentile rank of the abdominal circumference (greater than or equal to 90%, greater than 5% and less than 90%, and less than or equal to 5%). Regression analyses were performed to generate three formulas for estimating fetal weight on the basis of the following: Gestational age (weeks) + Head circumference (cm) + 2 x Abdominal circumference (cm) + Femur length (cm). This mathematic model allowed formulation of accurate and concise tables relating the sum of these measurements to estimated birth weight. The accuracy of these formulas was then prospectively compared, first, with the formula published by Hadlock et al. (in 32 large-, 279 appropriate-, and 70 small-for-gestational-age fetuses) and second, with the formula of Weiner et al. (in 82 preterm fetuses). The difference between actual and estimated birth weights generated by the three study formulas had no systemic error (t test, p greater than 0.05). Cumulatively, there was a statistically significant reduction of random error in the birth weight estimates by use of the three study formulas versus the best single formulas of Hadlock et al. (2 SD reduced from 21.6% to 19.8% and absolute 2 SD reduced from 15.6% to 12.2%). Additionally, the three study formulas resulted in a statistically significant reduction in the absolute 2 SD error compared with the best formula by Weiner et al. in fetuses less than or equal to 34 weeks' gestation (2 SD reduced from 19.1% to 13.6%).

We report the outcomes of 95 expectantly managed cases of placenta previa; all were diagnosed after 21 weeks' gestation. Patients at risk for preterm delivery because of hemorrhage or preterm labor received aggressive care, including multiple transfusions, volume expansion and tocolytic therapy, and amniotic fluid surfactant determinations, to achieve the goal of delivery at 37 weeks' gestation with mature fetal lung function. We present guidelines for outpatient management and double setup examination prior to delivery. The role of ultrasound in diagnosis (three asymptomatic cases; 13 cases with preterm labor) and serial placental localization to determine the timing, route, and place of delivery is presented. Eighty-six percent of 19 infants born weighing less than 2500 gm were managed expectantly. Hemorrhage was the determinant in delivery timing in 50 cases. All four deaths were neonatal with birth weights less than 2200 gm. This is the lowest perinatal mortality rate (4.2%) published to date. Use of this aggressive approach is particularly suitable for patients cared for in a teritary center.

This case report describes the antenatal diagnosis of a fetal pulmonary anomaly. Early detection afforded detailed parental counseling and prompt neonatal diagnosis and treatment.

The ultrasonically derived fetal abdominal circumference is one of the essential parameters used to predict birth weight, assess fetal growth, and follow the evolution of fetal ascites. Growth curves relating abdominal circumference to gestational age have been reported for directly measured abdominal circumferences. However, none have been reported for abdominal circumferences calculated from measurements of fetal abdominal diameters. In this report, 197 normal fetuses ranging from 18 to 41 weeks' gestation are studied. The validity of 468 abdominal circumferences calculated from fetal abdominal diameters is tested by comparing the data with a similar number of direct abdominal circumference measurements obtained by a digitizer. From 18 to 41 weeks' gestation, directly measured fetal abdominal circumferences are significantly larger than fetal abdominal circumferences calculated from abdominal diameters (P less than .0001). The authors conclude that clinical management decisions based on abdominal circumference data are predicated on the use of appropriate abdominal circumference and/or abdominal diameter growth curves.

Apgar scores and umbilical cord arterial pH measurements of 449 singleton breech deliveries are compared retrospectively to those of 1425 singleton vertex neonates. In the vaginal deliveries the Apgar scores and umbilical arterial pH were higher for the vertex neonates. There were no differences in either Apgar scores or umbilical arterial pH between the breech and vertex neonates delivered by cesarean section. Whereas Apgar scores in the less than 1000 g and greater than or equal to 2500 g weight groups were lower in the breech neonates delivered vaginally compared to cesarean section, umbilical arterial pH measurements were similar. The data suggest that liberal use of cesarean section may improve the Apgar scores but will probably not appreciably improve the acid-base status of the breech neonate.

Based on ultrasonographic mensuration, a number of equations have previously been devised for the purpose of estimating fetal weights. The objective of this study was to develop a mathematical equation that is simple, accurate, and easy to use when applied to preterm or low-birth weight fetuses (less than 2,500 gm). Real-time ultrasound measurements of fetal biparietal diameters (BPDs) and abdominal circumferences (ACs) were obtained in 62 pregnant women within one week of premature delivery. Mean gestational age and mean birth weight +/- SD for this study group of neonates were 28.5 +/- 3.5 weeks and 1,135 +/- 343 gm, respectively. With the aid of computer analysis, a simple regression equation was derived: EFW = (BPD x AC x 9.337) - 229. When predicted estimated fetal weight (EFW) was compared with actual birth weight (ABW), multiple regression analysis demonstrated a correlation coefficient (R) of 0.957. Preliminary results on 19 patients of a prospective study showed an absolute mean difference between the computed EFWs and the ABWs to be within 7.0% of ABW (70 gm/kg of ABW). The standard deviation of the difference was 9.3% of ABW (93 gm/kg of ABW). Based on these data, this simple equation appears to be clinically reliable and easy to use when estimating weights of preterm or low-birth weight fetuses of less than 2,500 gm.

In this report the predictive value of ultrasonic targeted imaging for fetal anomalies (TIFFA) is defined. Six hundred fifteen pregnant women at high risk for birth defects were scanned from January, 1980, to December, 1983. Follow-up evaluation was available on 569 fetuses. The pregnancies were classified into five groups according to the indications used for ultrasonic targeted imaging studies. The largest number of women were placed in group 1 and were referred because of a variety of abnormalities in previous or ongoing pregnancies. The women classified in the other four groups were examined because of maternal or fetal reasons related to specific craniospinal (29%), urinary (7.9%), gastrointestinal (6.7%), and skeletal (3.7%) defects. In our series the predictive values of abnormal and normal ultrasonic targeted imaging studies were 95% and 99%, respectively. A detailed breakdown of the accuracy of ultrasonic targeted imaging in relation to each anatomic category is presented; these data are useful in counseling gravid women with anomalous fetuses.

The rhesus-sensitized fetus with the worst prognosis is one with early onset of hydropic changes. Percutaneous umbilical blood sampling now enables access to the fetal circulation and thereby allows more precise evaluation of fetal anemia and direct intravascufar transfusion. A variation of this technique was used in three pregnancies complicated by fetal pericardial effusion, scalp edema, and abdominal ascites before 26 weeks' gestation. Twelve ultrasound-guided percutaneous transfusions of 30 to 85 ml packed red blood cells were administered into the umbilical cord at its placental insertion. In each fetus the hydropic changes completely resolved and pregnancy outcome was successful. Neither adjunctive therapy with digoxin or Lasix nor exchange transfusions were used. Percutaneous umbilical transfusions appear to have the potential to improve the prognosis for the severely isoimmunized fetus.

Sonar biparietal diameter, head circumference, and abdominal circumference percentile values obtained late in the third trimester were compared with birth weight percentile (relative to dates) in 147 diabetic mothers and 40 control fetuses of nondiabetics. Estimates of fetal weight by the method of Shepard et al were also calculated from these sonar data and compared with birth weight percentile. Abdominal circumference values greater than the 90th percentile correctly predicted macrosomia (defined as birth weight greater than 90th percentile) in 78% of cases. Biparietal diameter and head circumference percentiles were significantly less predictive of macrosomia. When analyzed in a similar manner, estimated fetal weights greater than the 90th percentile correctly predicted macrosomia at birth in 74% of cases. However, when both the abdominal circumference and the estimated fetal weight exceeded the 90th percentile, macrosomia was correctly diagnosed in 88.8% of pregnant women with diabetes mellitus.