The Impact of Maternal Body Mass Index and Gestational Age on the Detection of Uterine Contractions by Tocodynamometry: A Retrospective Study.

OBJECTIVE: To examine the impact of maternal body mass index (BMI) and gestational age (GA) on uterine contraction detection by tocodynamometry. METHODS: Gravidas with preterm labor (PTL) complaints who were evaluated by tocodynamometry, discharged from Labor and Delivery triage, and subsequently readmitted for preterm delivery were studied. Forty-six patients in whom contractions were detected (group 1) were compared to 49 women in whom contractions were not detected (group 2) with respect to BMI and GA at both evaluation and delivery. Multivariable logistic regression was used to adjust for confounders. RESULTS: Group 2 had a higher mean BMI (31.7 vs 26.1, P < .001), were more likely to be obese (57.1% vs 19.6%, P < .001), and were more likely to have been evaluated in the mid-trimester (36.7% vs 17.4%, P = .04) compared to group 1. Independent risk factors for the inability of the tocodynamometer to detect contractions were obesity (odds ratio [OR] 0.18, 95% confidence interval [CI] 0.07-0.46) and evaluation in the mid-trimester (OR 0.33, 95% CI 0.13-0.84). CONCLUSION: Our study provides evidence that the effectiveness of tocodynamometry diminishes with increasing maternal BMI. Efficacy of tocodynamometry is also decreased at earlier GA, most pronounced below 25 weeks. To evaluate women with PTL symptoms in the mid-trimester or symptomatic obese women at any GA, a modality other than tocodynamometry could be valuable to more accurately assess uterine activity.

Evidence of intrapartum hypoxia-ischemia is not present in the majority of cases of neonatal seizures.

OBJECTIVE: To determine the extent to which neonatal seizures are associated with intrapartum hypoxia-ischemia. METHODS: In this case-control study, all neonates diagnosed with seizures at a single institution from 1988 to 1999 were compared to a control group without seizures matched in a 2:1 fashion for gestational age at delivery, birth weight and mode of delivery. Data were abstracted from the maternal and neonatal charts. Parametric variables were compared using an independent samples t test, and non-parametric variables were compared using a Fisher exact test, with p < 0.05 being considered significant. RESULTS: There were 13 cases of neonatal seizures identified, of which one was chromosomally abnormal and excluded from further analysis. For the cases, the mean gestational age at delivery was 34.8 +/- 6.9 weeks, with four preterm and eight term deliveries. The mean birth weight for the cases was 2684 +/- 1369 g (range 590-4350 g). For both cases and controls, 83% were delivered vaginally and 17% by Cesarean section. For term neonates with seizures, the mean length of stay was 11.6 +/- 5.0 days, as compared to 2.5 +/- 0.9 days in the control group (p < 0.001). A 1-min Apgar score of < 7 was found in six of 12 (50%) cases and seven of 24 (29%) controls, and a 5-min Apgar score of < 7 was found in four of 12 (33%) cases and four of 24 (17%) controls (non-significant). In the controls, the mean base excess was -2.8 +/- 2.6 mEq/l, and the mean umbilical arterial pH was 7.28 +/- 0.09. In the case group, two infants born at 24 weeks did not have an umbilical arterial blood gas obtained; in the remaining cases, the mean base excess was -7.6 +/- 6.9 mEq/l (p = 0.02), and the mean cord pH was 7.17 +/- 0.23 (p = 0.065), with only three of ten (30%) having a pH < 7.00 (p = 0.02). CONCLUSION: Clinically significant acidosis was found in only 30% of neonates who developed seizures, and only one of 12 cases (8%) could possibly have met the criteria of the American College of Obstetricians and Gynecologists for neurological morbidity linked to intrapartum asphyxia. The majority of cases of neonatal seizures were not associated with evidence of intrapartum hypoxia-ischemia.

Alagille syndrome: prenatal diagnosis and pregnancy outcome.

The Alagille syndrome (AGS) is a multisystem autosomal dominant condition. In this case report, we describe a pregnant woman with this unusual disorder, in whom serial fetal sonography revealed severe pulmonary stenosis and progressively severe intrauterine growth retardation, suggesting that the fetus also had AGS, a diagnosis which was confirmed postnatally. In this report, the potential complications for pregnancy, labor and delivery when both mother and fetus are affected with AGS are described.

Pathogenesis of acardiac twinning: clues from an almost acardiac twin.

OBJECTIVE: To search for clues to the pathogenesis of acardiac twinning. METHODS: We examined a case of monoamniotic twins in which twin A's only sonographic abnormality was a dilated, tortuous ductus venosus. Twin B also had this abnormality as well as multiple other anomalies that included enormous hydrops and a severely hypoplastic heart. Following termination of pregnancy, autopsy was performed. RESULTS: Postmortem examination of the placenta confirmed monochorionic, monoamniotic placentation with two adjacent trivascular cords. Autopsy confirmed the sonographic findings of enormous hydrops in twin B with a severely malformed, almost nonexistent heart. In addition, the liver was small and was represented by a cyst-like structure with thin rims of congested parenchyma surrounding large vascular spaces. CONCLUSION: We believe the sequence of events in this case was early twin-to-twin transfusion resulting in a dysfunctional heart in twin B. This enabled a twin reversal arterial perfusion sequence with further deterioration of twin B's heart and extreme congestion of deoxygenated blood exiting the heart into the inferior vena cava and ductus venosus. This case supports the concept that circulatory reversal in the face of an initially functioning heart may lead to congestion, tissue hypoxia and secondary organ atrophy.

Early second trimester prenatal diagnosis of Neu-Laxova syndrome.

Neu-Laxova is a rare, uniformly lethal, autosomal recessive condition with characteristic limb posturing, facial dysmorphic features, and central nervous system abnormalities. Forty-two cases of Neu-Laxova syndrome have been reported, with only four of these diagnosed prenatally. Three of the four cases were diagnosed at or after 32 weeks' gestation. The fourth case was diagnosed at 22 weeks' gestation in a patient who was followed with serial ultrasound studies due to having a prior affected child. At 19 weeks' gestation, we present the earliest reported prenatal diagnosis of Neu-Laxova syndrome in a primigravida with a non-informative family history.

The degree of antenatal ventriculomegaly is related to pediatric neurological morbidity.

OBJECTIVE: Our hypothesis was that the degree of antenatally diagnosed cerebral ventriculomegaly is related to aneuploidy, perinatal mortality and long-term neurological morbidity. METHODS: Ninety-one cases of ventriculomegaly identified from 1 June 1994 to 1 July 1999 were examined for prenatal, intrapartum and neonatal complications. Pediatric follow-up was reviewed for infants with ventriculomegaly from birth up to as long as 4 years. Minor neurological morbidity was defined as a score of 70-80 on the clinical adaptive test/clinical linguistic and auditory milestone scale and included mild motor or language delay. Major morbidity included a score of < 70, evidence of cerebral palsy, or seizure disorder. The incidence of neurological complications was compared, on the basis of the degree of ventriculomegaly, with group 1 being > 10-15 mm and group 2 being > 15 mm. RESULTS: Twenty-seven cases (18 with neural tube defects and nine with holoprosencephaly) were excluded. Among the remaining 64 patients, 39 had a ventricular diameter of > 10-15 mm and comprised group 1. Five of the 39 cases (12.8%), all with other ultrasound anomalies, elected to terminate. The incidence of aneuploidy in group 1 was 14.2%. Among the 19 cases with isolated ventriculomegaly, 17 (89%) were normal and two (11%) had minor neurological morbidity. In group 1 there were two cases associated with cytomegalovirus (CMV) infection. Of the 25 cases in group 2, eight (32%), all with other ultrasound anomalies, elected to terminate. The incidence of aneuploidy in group 2 was 17.4%. For the nine cases with isolated ventriculomegaly of > 15 mm, one (11%) was normal (p < 0.001), five (56%) had minor neurological morbidity requiring a ventriculoperitoneal shunt (p = 0.035), and three (33%) had major neurological morbidity (p = 0.045) when compared to cases of isolated ventriculomegaly in group 1. There was one case of CMV infection in group 2. All perinatal deaths in both groups were associated with other anomalies. CONCLUSIONS: Amniocentesis to determine karyotype and the presence of CMV is warranted for all cases of ventriculomegaly of > 10 mm. The degree of antenatal ventriculomegaly is related to pediatric neurological morbidity and, when it is > 15 mm, it is associated with an increase in abnormal neurological development.

University hospital-based prenatal care decreases the rate of preterm delivery and costs, when compared to managed care.

OBJECTIVE: Our purpose was to compare the rate of recurrent preterm delivery and the combined costs of mother/infant care for patients with a history of preterm delivery cared for in an inner city hospital house staff (HS) clinic versus an inner city managed care organization (MCO). METHODS: A retrospective cohort study was conducted. The groups consisted of 96 patients with a history of preterm delivery who were cared for by the HS clinic and 164 patients cared for in a neighborhood MCO. All patients with a history of previous preterm delivery who delivered at the Johns Hopkins Hospital between 1 January 1994 and 31 December 1996 were included in the study. The groups were examined regarding source of prenatal care for the subsequent pregnancy (HS vs. MCO), baseline demographics, intensity of prenatal care, maternal and neonatal outcomes and total cost of the provision of care. RESULTS: There were no differences in baseline demographics between the groups. There was a higher rate of recurrent prematurity for patients cared for by the MCO (HS, 24% vs. MCO, 36%, p = 0.04). Mean total mother/infant costs were also higher in the MCO group ($13565) when compared to the HS group ($9082), (p = 0.02). CONCLUSION: While some MCOs may provide cost savings for some low-risk populations, our study demonstrates that this health-care delivery system resulted in greater total expenditures for patients with a history of preterm delivery.

Non-mosaic trisomy 20 presenting at 21 weeks' gestation as a thoraco-abdominal mass.

Non-mosaic trisomy 20 is rare in fetuses surviving beyond the first trimester. We report a case of a fetus with non-mosaic trisomy 20 in amniotic fluid cultures obtained during the prenatal evaluation of an unusual thoraco-abdominal mass which was found at autopsy to be pulmonary sequestration. Gross inspection and autopsy of the fetus revealed multiple anomalies.

Cloacal outlet obstruction with an ectopic ureter.

Cloacal malformation occurs in approximately 1 in 50,000 live female births. Prenatal ultrasound may lead to the diagnosis in selected cases. We report an unusual case of prenatally detected single-system hydronephrosis with a nonvisible bladder and worsening oligohydramnios. Labor was induced at 35 weeks' estimated gestational age. On physical examination, a single perineal opening was noted consistent with cloaca. Endoscopy revealed an obstructed ectopic ureter at the level of the sphincter, an undeveloped bladder and vagina, and a fistula to the rectum. A low loop cutaneous ureterostomy and right upper quadrant loop colostomy were performed. The absence of a typical fluid-filled pelvic structure may confound the prenatal diagnosis of cloaca.

Prediction of birth weight by ultrasound in the third trimester.

OBJECTIVE: To compare the accuracy of predicted birth weight by the gestation-adjusted projection method using ultrasonographic measurements obtained just before and at term. METHODS: The study group comprised patients with singleton pregnancies who underwent sonograms between 34.0 and 36.9 weeks' gestation (period 1) and at 37 weeks and beyond (period 2). The mean error in birth weight prediction, absolute birth weight error, and signed and absolute percent errors were compared with paired t tests. Thus, each patient served as her own control. RESULTS: The study included 138 patients undergoing 276 sonograms. The mean absolute error of the predicted birth weight was smaller for period 1 than for period 2 (197 +/- 167 g compared with 235 +/- 209 g, P =.019). The mean absolute percent error was 6.2 +/- 5.2% for period 1 compared with 7.4 +/- 6.3% for period 2 (P =.019). These same trends were observed when fetuses with suspected growth abnormalities were examined separately. Averaging data from both gestational periods did not improve the prediction of birth weight. CONCLUSION: Sonograms between 34.0 and 36. 9 weeks' gestation allow for more accurate prediction of birth weight than sonograms later in gestation. Though these differences are small and not clinically significant, this study indicates that serial sonograms in the late third trimester do not improve the ability to predict birth weight, even in abnormally grown fetuses. A single sonogram between 34 and 37 weeks' gestation is recommended for prediction of birth weight.

Molecular cytogenetic analysis and clinical findings in a newborn with prenatally diagnosed rec(7)dup(7q)inv(7)(p22q31.3)pat.

We report prenatal and early postnatal findings in a newborn with a partial trisomy of chromosome 7 (7q31.3-qter), arising from meiotic recombination of a paternal pericentric inversion, inv(7)(p22q31.3). The inversion breakpoints were localized and the regions of duplication and deletion were defined by fluorescence in situ hybridization (FISH) analysis using a series of locus-specific and subtelomeric probes. To our knowledge, only three cases involving a recombinant 7 with duplication of 7q have been reported, two of these being first cousins. The clinical findings in our patient included skeletal abnormalities, facial dysmorphism, dilated cerebral ventricles, microretrognathia and short neck. These findings and some aspects of the neonatal course were consistent with the phenotype previously reported for duplication of distal 7q, without associated monosomy for sequences from another chromosome.

Second-trimester maternal serum analyte levels associated with fetal trisomy 13.

The aim of this study was to determine whether pregnancies affected by fetal trisomy 13 are associated with second-trimester maternal serum analyte levels different from those typical of the unaffected population. Pregnancies with trisomy 13 were identified through cytogenetics laboratories. Those which had second-trimester maternal serum screening analyte measurements were further evaluated. Maternal serum analyte levels for each case and five matched controls were statistically analysed by matched ranked-sum analysis. 28 cases of fetal trisomy 13 were identified. The median AFP, uE3 and hCG levels were 1.35 MoM, 0.71 MoM and 0.90 MoM, respectively. Only uE3 levels were statistically different (p < 0.01) from those for the unaffected population. These data suggest that second-trimester maternal serum AFP, uE3 and hCG levels are not useful in detecting fetal trisomy 13 and protocols already existing for Down syndrome or trisomy 18 screening will not detect the majority of cases of this aneuploidy.

Preterm labor, placental abruption, and premature rupture of membranes in relation to maternal violence or verbal abuse.

OBJECTIVE: The prevalence of preterm labor (PTL) in prenatal populations has been estimated to be from 6.9 to 10.0%. It has been suggested that violence during pregnancy may be associated with an increase in antenatal complications. The hypothesis is that physical violence and verbal abuse in pregnancy lead to increased risk of PTL. METHODS: A cohort of 636 women attending the Adult Obstetrical Clinic for their first prenatal visit, between December 1989 and September 1990, were approached; 567 women enlisted as study participants. Study participants were interviewed 3 times during the course of their prenatal care, and 401 participants successfully completed their third prenatal interviews. Violence data were obtained during the third interview. Obstetrical and neonatal outcome data were obtained by abstracting the maternal and neonatal medical records. RESULTS: When stratified by levels of violence, women who experienced moderate or severe violence had incidences of PTL of 15.4 and 17.2%, respectively. Chi-square test for homogeneity revealed a significant difference among these groups. CONCLUSIONS: In our cohort of women, serious acts of verbal abuse and physical violence occurred with significant frequency. PTL was strongly correlated with increasing acts of violence with 4.1 times greater risk of PTL in women who experienced severe violence as compared to those who experienced no maternal abuse.

A human-murine chimera model for in utero human hematopoietic stem cell transplantation.

To date, 16 in utero hematopoietic stem cell (HSC) transplants for diseases other than immunodeficiency disorders have been reported. No therapeutic level of engraftment was detected in 15 of these transplants. To overcome engraftment failure, we transplanted a very large number (5 billion paternal CD34+ cells/kg) of HSCs to a fetus with leukodystrophy during the first trimester of gestation. As reported previously, the fetus died in utero 7 weeks after the procedure and the cause of death appeared to be overwhelming donor engraftment. In the present investigation, we developed a human-murine chimera model to test for the optimal donor cell dose for human in utero transplantation. We found a strong correlation between the level of donor engraftment in three human fetuses transplanted for leukodystrophy during the first trimester of gestation and the results of parallel xenotransplants of the same human donor cells using the NOD/SCID mouse model. This small animal model appears to predict both extremes of hyperengraftment (seen in the first human fetus transplanted) and engraftment failure (seen in the second and third human fetuses transplanted in utero). These and future correlated clinical and laboratory assay results may be useful for the development of in utero transplants for a variety of congenital disorders.

Helical CT amniography of congenital diaphragmatic hernia.

OBJECTIVE: Accurate prenatal diagnosis of congenital diaphragmatic hernia is important for perinatal planning and potential fetal surgery. We describe the application and usefulness of helical CT amniography in the evaluation of suspected congenital diaphragmatic hernia in three fetuses. CONCLUSION: Helical CT amniography is an efficient means for evaluation of congenital diaphragmatic hernia. Accurate diagnosis was made in all three patients.

Station at onset of active labor in nulliparous patients and risk of cesarean delivery.

OBJECTIVE: To determine whether term nulliparas with an unengaged vertex presentation at onset of active labor have a higher risk for cesarean delivery. METHODS: A retrospective cohort of 1250 randomly chosen nulliparous patients at 37-42 weeks' gestation who delivered between 1988 and 1989 were selected. Four hundred forty-seven patients were excluded because of nonvertex presentation, cesarean delivery before active phase of labor, multiple gestation, delivery at less than 37 weeks' or greater than 42 weeks' gestation, induction of labor, or missing charts. For the purpose of this study, active labor was defined as regular contractions with cervical dilatation of at least 3 cm. The station at onset of active labor was recorded. Engagement was considered to be at station 0 or below. RESULTS: Of the 803 patients in the study group, 567 presented unengaged and 236 patients presented engaged. The cesarean rates differed significantly between the two groups: 14% of those unengaged compared with 5% of those engaged (chi2 = 11.9, P < .001). After adjusting for confounding variables, engagement at the time of onset of active labor was associated with lower risk of cesarean delivery (odds ratio .512, 95% confidence interval .285, .922). CONCLUSION: Eighty-six percent of nulliparas with an unengaged vertex at onset of active labor delivered vaginally. Engaged vertex at the onset of active labor was associated with a lower risk of cesarean delivery.

A novel factor produced by placental cells with activity against HIV-1.

The factors controlling the dynamics of HIV-1 transmission from mother to infant are not clearly known. Previous studies have suggested the existence of maternal and placental protective mechanisms that inhibit viral replication in utero. Preliminary studies from our laboratory revealed that supernatant from placental stromal cells protected HIV-1-infected PBMC from virus-induced apoptosis and suppressed virus production. We have attempted to characterize the antiviral activity of this placental factor (PF) and delineate the stages of HIV-1 replication affected. This activity was not due to the presence of any known cytokine reported to have anti-HIV effect. Direct exposure to PF had no suppressive effect on the infectivity of cell-free HIV-1, and envelope-mediated membrane fusion appeared to be unaffected. Western blot analysis of HIV-1 from infected PBMC treated with PF revealed that expression of all viral proteins was reduced proportionately, both intracellularly and in released virions. However, exposure of HIV-1-infected cells to PF resulted in production of virions with 10-100-fold-reduced infectivity. PF-treated virions contained two- to threefold reduced ratios of cyclophilin A:Gag protein as compared with untreated virus. Reduced cyclophilin A content resulting in decreased binding of cyclophilin A to Gag could account, in part, for the observed reduction in infectivity. Our results suggest that placental cells produce an antiviral factor that protects the fetus during gestation and may have therapeutic potential.

Complete trisomy 9 in a term fetus: a case report.

Complete trisomy 9 was diagnosed in a 35-week fetus by amniocentesis. Several sonograms had revealed only a two-vessel cord and intrauterine growth restriction. No other abnormalities were noted. A stillborn infant was delivered at 37 weeks gestation after induction of labor.

Region-specific FISH probes used to identify and characterize an interstitial paracentric inv(21)(q22.1q22.3).

Region-specific probes developed for the diagnosis of specific syndrome, can be adapted to elucidate the exact nature of certain chromosomal structural anomalies. We describe the use of FISH probes in characterizing a prenatally diagnosed chromosome rearrangement. An abnormal chromosome 21 was detected during amniocentesis for maternal age indication, and a similar appearing chromosome 21 was found in the mother. The exact nature of the rearrangement was not immediately evident from G-banded karyotypes. FISH was performed using a whole chromosome painting probe, as well as the region-specific probes D21S65 (21q21-22.1), D21S55 (21q22.3) and D21S1219/D21S1220 (21q22.3-qter) (Oncor). Results showed an interstitial paracentric inversion, with breakpoints in bands 21q22.1 and 21q22.3, which was identical in the mother and the fetus: 46,XX,?inv(21)(q).ish inv(21)(q22.1q22.3)(wcp+.D21S65 mv, D21S55 mv, D21S1219/D21S1220 st). In this case, FISH using region-specific probes was helpful in characterizing the inversion and aided in the genetic counselling of risk assessment for the family.