Prediction of neonatal outcome in women with gestational hypertension or mild preeclampsia after 36 weeks of gestation.

BACKGROUND: There is little knowledge about neonatal complications in GH and PE and induction at term, we aim to assess whether they can be predicted from clinical data. METHODS: We used data of the HYPITAT trial and evaluated whether adverse neonatal outcome (Apgar score < 7, pH < 7.05, NICU admission) could be predicted from clinical data. Logistic regression, ROC analysis and calibration were used to identify predictors and evaluate the predictive capacity in an antepartum and intrapartum model. RESULTS: We included 1153 pregnancies, of whom 76 (6.6%) had adverse neonatal outcome. Parity (primipara OR 2.75), BMI (OR 1.06), proteinuria (dipstick +++ OR 2.5), uric acid (OR 1.4) and creatinine (OR 1.02) were independent antepartum predictors; In the intrapartum model, meconium stained amniotic fluid (OR 2.2), temperature (OR 1.8), duration of first stage of labour (OR 1.15), proteinuria (dipstick +++ OR 2.7), creatinine (OR 1.02) and uric acid (OR 1.5) were predictors of adverse neonatal outcome. Both models showed good discrimination (AUC 0.75 and 0.78), but calibration was limited (Hosmer-Lemeshow p = 0.41, and p = 0.20). CONCLUSIONS: In women with GH or PE at term, it is difficult to predict neonatal complications, possibly since they are rare in the term pregnancy. However, the identified individual predictors may guide physicians to anticipate requirements for neonatal care.

Is 3D technique superior to 2D in Down syndrome screening? Evaluation of six second and third trimester fetal profile markers.

OBJECTIVE: The objective of this article is to investigate whether in the clinical setting of second trimester ultrasound (US) investigations, 3D multiplanar correction prior to the measurement of Down syndrome (DS) facial markers (nasal bone length, prenasal thickness, fetal profile line, maxilla-nasion-mandible angle, prenasal thickness to nasal bone length ratio, and prefrontal space ratio) is superior to subjective judgment of a correct midsagittal plane by 2D technique. METHODS: Measurements were performed on 2D images and 3D volumes (corrected to the midsagittal plane), acquired during the same scanning session. RESULTS: All six markers were measured in 105 datasets (75 of euploid fetuses and 30 of DS fetuses). The maxilla-nasion-mandible angle measured on 2D images was significantly larger than on 3D volumes (p < 0.01). In all other markers, there was no significant difference between measurements performed on 2D images or 3D volumes. No statistical difference was found for any marker between measurements performed on images acquired by either 2D or 3D US in their ability to discriminate between normal and DS fetuses. CONCLUSIONS: Nasal bone length, prenasal thickness, fetal profile line, prenasal thickness to nasal bone length ratio, and prefrontal space ratio can be confidently used as DS markers in second trimester US examinations performed by 2D US. © 2014 John Wiley & Sons, Ltd.

Premaxillary protrusion assessment by the maxilla-nasion-mandible angle in fetuses with facial clefts.

OBJECTIVE: The aim of the study was to measure the degree of premaxillary protrusion in fetuses with orofacial clefts of various severities. METHODS: The maxilla-nasion-mandible (MNM) angle was measured retrospectively on by multiplanar corrected volumes. Sixty-two fetuses with orofacial clefts and known outcome volumes of the fetal head were available. RESULTS: In 48 of the 62 cases, the MNM angle could be measured [mean gestational age 23 (range, 18-30) weeks]. The mean MNM angle was normal in all nine cases with cleft lip and intact alveolar ridge (15.2°; range, 12.5°- 16.9°). In 24 cases with unilateral cleft lip with or without cleft palate (UCL/P), the mean MNM angle was 20.0° (range, 13.3-26.2°), being above the 95th percentile in 79% (n = 19) and normal in 21% (n = 5). In 14 bilateral cleft lip and palate (BCL/P) cases, the mean MNM angle was 26.5° (range, 19.2°-33.7°) and above the 95th percentile in all cases. There was no difference in MNM angle between isolated clefts and clefts associated with other anomalies. In one case with a Tessier 4 cleft, the MNM angle was above the 95th percentile (25.2°). CONCLUSION: The premaxilla tends to protrude in both BCL/P as UCL/P cases. The degree of protrusion varies greatly, especially in the BCL/P group.

Three-dimensional ultrasound and maternal bonding, a third trimester study and a review.

OBJECTIVE: To compare the effect of third trimester three-dimensional and four-dimensional (3D/4D) versus two-dimensional (2D) ultrasound (US) of the fetal face on maternal bonding. Studies quantifying the psychological effect of 3D/4D US on mothers, pregnant of a fetus with no detectable abnormalities, were reviewed. METHODS: One hundred sixty Caucasian women attended a third trimester 3D/4D or 2D US examination. Women filled out the Maternal Antenatal Attachment Scale (MAAS) 1 to 2 weeks before (MAAS1) and 1 to 2 weeks after (MAAS2) the US examination. Visibility, recognition and attractiveness were assessed. RESULTS: Within both US groups, the MAAS2 scores were significantly higher than the MAAS1 scores (p < 0.0001). No differences in MAAS scores between the US groups emerged. Visibility and recognition were significantly positively related with the increase in MAAS scores (p = 0.003 and p = 0.042) in the 3D/4D group. Of 13 psychological studies, eight studies evaluated bonding and found no difference between 3D/4D and 2D US. The effect of 3D/4D US on satisfaction or perception showed conflicting results, and on anxiety/stress, reduction was the same as after 2D US. CONCLUSIONS: Bonding increases after either a 3D/4D or 2D US. The effect of 3D/4D US on bonding is stronger at better degrees of visibility and recognition.

Prenasal thickness-to-nasal bone length ratio: a strong and simple second- and third-trimester marker for trisomy 21.

OBJECTIVES: To study the ratio of prenasal thickness (PT) to nasal bone length (NBL) in normal and trisomy-21 fetuses in the second and third trimesters of pregnancy. METHODS: The PT and NBL were measured retrospectively in 106 normal fetuses (in three-dimensional (3D) volumes) and in 30 fetuses with trisomy 21 (10 on two-dimensional (2D) images and 20 in 3D volumes). RESULTS: In normal fetuses the mean PT and NBL increased between 15 and 33 weeks' gestation from 2.3 to 6.1 mm (r = 0.85, P < 0.001) and from 3.3 to 9.6 mm (r = 0.87, P < 0.001), respectively. The PT : NBL ratio was stable throughout gestation, with a mean of 0.61 (95% CI, 0.59-0.63; r = - 0.04, P = 0.7). The 5(th) and 95(th) percentiles were 0.48 and 0.80, respectively. In trisomy-21 fetuses the mean PT and NBL increased between 14 and 34 weeks from 3.0 to 9.2 mm (r = 0.86, P < 0.001) and from 1.9 to 7.8 mm (r = 0.85, P < 0.001), respectively. The PT : NBL ratio was significantly higher than in normal fetuses (P < 0.001) but also stable throughout gestation, with a mean of 1.50 (95% CI, 1.20-1.80; r = - 0.35, P = 0.07). Twenty-three (77%) of the 30 fetuses with trisomy 21 had a PT above the 95(th) percentile and 20 (67%) had an NBL below the 5(th) percentile. All the trisomy-21 fetuses had a PT : NBL ratio above the 95(th) percentile. When the 95(th) percentile of the PT : NBL ratio was used as a cut-off value the detection and false positive rates for trisomy 21 were 100 (95% CI, 89-100)% and 5 (95% CI, 2-11)%, respectively. The positive likelihood ratio was 21.2. CONCLUSIONS: The PT : NBL ratio is stable in the second and third trimesters of pregnancy in both normal and trisomy-21 fetuses, but all trisomy-21 fetuses in this series had a PT : NBL ratio above the 95(th) percentile. The ratio is therefore a strong marker for trisomy 21.

Three-dimensional ultrasound imaging and measurement of nasal bone length, prenasal thickness and frontomaxillary facial angle in normal second- and third-trimester fetuses.

OBJECTIVES: To assess the feasibility of nasal bone length (NBL), prenasal thickness (PT) and frontomaxillary facial (FMF) angle measurements performed on the same three-dimensional (3D) multiplanar-corrected profile view in healthy second- and third-trimester fetuses, to create reference ranges and to review published measurement techniques. METHODS: 3D volumes of 219 healthy second- and third-trimester fetuses were retrospectively analyzed. The quality of images and measurability of the markers were assessed with 5-point and 3-point scoring systems, respectively. Measurements of NBL (with care to exclude the frontal bone), PT and FMF were obtained in the exact mid-sagittal plane. Reference ranges were constructed based on measurements from images with high-quality (4 or 5 points) and high measurability (2 or 3 points) scores and compared with those in the most relevant published literature. RESULTS: A high-quality score was assigned to 111 images. Among these, a high measurability score was significantly more often achieved for NBL (98.2%) and PT (97.3%) than for the FMF angle (26.1%) (P < 0.001). Both NBL (NBL = - 6.927 + (0.83 × GA) - (0.01 × GA(2))) and PT (PT = (0.212 × GA) - 0.873) (where GA = gestational age) showed growth with gestation, with less pronounced growth for NBL after 28 weeks. Our reference range for the NBL showed a systematically smaller length than those in other two-dimensional (2D) ultrasound-based publications. The FMF angle measurements that we obtained did not show a significant change with GA. CONCLUSIONS: NBL and PT are easily measured using 3D ultrasound whereas FMF angle measurement is more challenging. When it is measured in the exact mid-sagittal plane and care is taken to exclude the frontal bone, measurements of the NBL are systematically smaller than those in previous 2D ultrasound-based publications.

Maxilla-nasion-mandible angle: a new method to assess profile anomalies in pregnancy.

OBJECTIVES: To collect normative data and test the feasibility and reproducibility of measurement of the maxilla-nasion-mandible (MNM) angle between 16 and 36 weeks' gestation and its diagnostic ability in a group of pathological cases. METHODS: The MNM angle is defined as the angle between the intersection of the maxilla-nasion and mandible-nasion lines in the exact mid-sagittal plane. After assessing reproducibility, the MNM angle was measured in 3D volumes in 241 fetuses cross-sectionally and in 11 fetuses longitudinally. The MNM angle was then tested in 18 pathological cases with facial malformations or syndromes with specific facial features. RESULTS: The MNM angle could be measured in 92.3% of normal fetuses. Intra- and interobserver intraclass correlation coefficient (ICC) variability was 0.92 and 0.81, respectively. The difference between paired measurements performed by one or two observers was less than 2.5° and 3.6°, respectively in 95% of the cases. The mean MNM angle was 13.5° and did not change significantly during pregnancy (r = - 0.08, P = 0.25). The MNM angle was above the 95(th) centile in all cases of retrognathia and maxillary alveolar ridge interruption. The MNM angle was below the 5(th) centile in Apert syndrome, thanatophoric dysplasia and in two of the three Down syndrome cases. CONCLUSIONS: The feasibility and reproducibility of measurement of the MNM angle is good. The MNM angle can be used to evaluate the convexity of the fetal profile by enabling an objective assessment of the anteroposterior relationship of the jaws and it may therefore be of help in the diagnosis of retrognathia, maxillary alveolar ridge interruption and flat profile.

Three-dimensional multiplanar ultrasound is a valuable tool in the study of the fetal profile in the second trimester of pregnancy.

OBJECTIVES: To evaluate the additional value of three-dimensional (3D) multiplanar ultrasound in the examination of the fetal profile. METHODS: Two 3D volumes of the fetal head were obtained from 84 fetuses at 22 to 29 weeks' gestation. The volumes were taken starting at the midsagittal plane with the fetus facing the transducer. The success rate and acquisition time to obtain each volume and display the exact midsagittal plane by 3D multiplanar ultrasound were analyzed. The correction angles from the original two-dimensional (2D) profile view to the exact midsagittal plane were noted. Of six measurements, related to the fetal nose and jaws, the success rate and the intraobserver reproducibility between the 2D and the 3D multiplanar ultrasound were compared. RESULTS: In 81 (96.4%) cases we succeeded in obtaining a profile volume, 70% of the volumes being obtained within 10 min. It was possible to define by multiplanar mode the exact midsagittal plane in less than 1 min. The mean rotation necessary to obtain the exact midsagittal plane with 3D multiplanar mode was significantly larger around the y-axis (11.9 degrees ) than around the z-axis (4.3 degrees ) of the fetus. For between 5 and 12% of the six measurements under investigation it was not possible to obtain values with 2D ultrasound. However, 3D ultrasound made these measurements possible in at least one volume. The intraobserver reproducibility was higher with 3D multiplanar ultrasound than with 2D ultrasound, this difference being statistically significant for five of the six measurements. CONCLUSIONS: 3D multiplanar ultrasound improves the topographic depiction of the midsagittal profile view, enables correct measurement of anatomical details and improves intraobserver reproducibility. 3D multiplanar ultrasound is a powerful instrument for investigating the fetal profile.

Unusual cause of sudden cardiac death: basophilic degeneration of coronary arteries.

Basophilic or mucoid degeneration of the intima in the coronary arteries is an extremely rare cause of premature atherosclerosis. An unusual case of fatal basophilic degeneration of the coronary arteries 142 days after delivery is reported.

Maternal serum screening for fetal Down syndrome in IVF pregnancies.

To assess the influence of in vitro fertilization (IVF) on maternal serum human chorionic gonadotrophin (hCG) and alpha-fetoprotein (AFP), the maternal serum hCG and AFP values were studied in 67 IVF pregnancies and compared with the results of a control group of 4732 spontaneously conceiving patients. Maternal serum hCG was significantly higher and AFP significantly lower in the IVF group. Possible explanations and implications for prenatal diagnosis in IVF pregnancies are discussed.

Prediction of fetal acidaemia in intrauterine growth retardation: comparison of quantified fetal activity with biophysical profile score.

OBJECTIVE: To study the relation between quantified fetal movements and fetal activity assessed by the biophysical profile score and the pH in umbilical arterial blood at elective caesarean section. DESIGN: Fetal activity was assessed within 24 h prior to caesarean section for decelerative fetal heart rate patterns both by quantification (% of time spent moving) and by applying the biophysical profile score (BPS) criteria. SETTING: Department of Obstetrics, University Hospital. SUBJECTS: Nineteen growth retarded fetuses. MAIN OUTCOME MEASURES: Fetal generalised movements (FGM%), fetal breathing movements (FBM%), total fetal activity (TFA% = FGM% + FBM%); FGM, FBM and tone as assessed according the biophysical profile score (BPS); umbilical arterial pH. RESULTS: In all 11 acidaemic fetuses (pH < 7.20) TFA% was below the 10th centile for normal fetuses; nine had decreased FGM% and eight decreased FBM%. Absence of FGM or tone according to the biophysical profile score was only seen in two acidaemic fetuses. CONCLUSION: TFA% < 11.7% was a better predictor of acidaemia at birth than either reduced FGM%, FBM%, or absence of FGM, FBM and tone as defined in the biophysical profile score. The two methods of assessing FBM were identical in predicting acidaemia, suggesting that in presence of acidaemia the decrease of FBM may be an all-or-none phenomenon. Furthermore, the data indicate that reduction in body movements may precede reduction in breathing movements.

Changes with time in fetal heart rate variation, movement incidences and haemodynamics in intrauterine growth retarded fetuses: a longitudinal approach to the assessment of fetal well being.

Fetal heart rate (FHR) variation, general movements (FGM), breathing movements (FBM) and haemodynamics were studied longitudinally in 19 intrauterine growth retarded fetuses, who eventually were delivered by caesarean section (CS) because of fetal distress, in order to determine changes occurring with time. The fetuses were studied for the last 10 days on average before delivery (range 2-14 days). During this period on average eight 1-h FHR records were made and three 1-h movement recordings. The FHR pattern was analyzed numerically; the incidence of FGM and FBM was quantified and expressed as percentage of time. Blood flow velocity waveforms were measured in the umbilical artery (n = 19) and in the internal carotid artery (n = 14). In 14 of 19 fetuses abnormal velocity wave forms were present from the beginning of the study onwards. FHR variation was initially just within or below the norm and fell further during the last 2 days before CS. FGM and FBM fell below the normal range later and in a lower rate of occurrence than FHR variation. FGM showed a more or less consistent fall in time, whereas FBM showed a wide range throughout the period of observation. The poorest outcome occurred in fetuses with reversed end-diastolic velocities and rapid fall in FHR variation. It is concluded that with progressive deterioration of the fetal condition abnormal velocity wave form patterns occur first; FHR variation is reduced subsequently and FGM and FBM are the last to become abnormal. Assessment of fetal activity may be of help in fetuses with a marginally reduced FHR variation, in which prolongation of pregnancy is considered desirable to allow further maturation in utero.

Numeric analysis of heart rate variation in intrauterine growth-retarded fetuses: a longitudinal study.

OBJECTIVE: We attempted to determine changes occurring with time in fetal heart rate and its variation in fetuses with intrauterine growth retardation in whom late antepartum fetal heart rate decelerations eventually develop. STUDY DESIGN: Thirteen fetuses with intrauterine growth retardation were studied over a median period of 25 days. One-hour fetal heart rate records were made two to five times per week and were analyzed numerically. Fetal movements were recorded by the women. RESULTS: On average long-term fetal heart rate variation decreased gradually with time and fell below the norm (30 milliseconds) at about the same time decelerations appeared. Mean heart rate showed a slight but statistically significant increase after the occurrence of decelerations. There were large interfetal differences in all parameters studied. CONCLUSION: In fetuses with intrauterine growth retardation a decrease in long-term fetal heart rate variation is a rather late sign of impairment that coincides with the occurrence of late decelerations. In the surveillance of the fetus with intrauterine growth retardation it might be most appropriate to use each fetus as its own control.

Continuous maternal hyperoxygenation in the treatment of early fetal growth retardation.

Continuous maternal hyperoxygenation treatment (2.5 l/min by means of a nasopharyngeal cannula) was given in four patients presenting with intrauterine growth-retarded (IUGR) fetuses and decelerative fetal heart rate (FHR) patterns at 27-28 weeks of gestation. The effect of maternal hyperoxia was studied longitudinally. Neither the incidence of generalized fetal movements (FGM%) nor the pulsatility index of the internal carotid artery increased under hyperoxia. In fact, both variables decreased progressively. FHR variation was abnormal prior to the start of hyperoxygenation and showed a slight but transient increase. On average, maternal hyperoxygenation 'resulted' in a prolongation of the duration of pregnancy of 9 days. The neonatal mortality was similar in the study group as compared to a control group of IUGR infants. However, hypoglycemia, thrombocytopenia and disseminated intravascular coagulation at birth were found more frequently in the study group. Conversely, blood gas abnormalities were less frequent in the fetuses of mothers that were treated with oxygen. We conclude that positive effects of oxygen therapy in IUGR fetuses remain uncertain and that detrimental effects due to prolongation of intrauterine malnutrition have not as yet been sufficiently excluded.

Relation of fetal blood gases and data from computer-assisted analysis of fetal heart rate patterns in small for gestation fetuses.

Fetal heart rate (FHR) monitoring and computer-assisted analysis were performed immediately before cordocentesis in 25 severely small-for-gestational age fetuses. There were significant associations between FHR variation and both umbilical vein blood PO2 (r = 0.66) and pH (r = 0.69). However, the wide scatter of values around the regression lines prevented accurate prediction of fetal blood gases from FHR patterns. Nevertheless, FHR variation less than 20 ms was always associated with severe fetal hypoxaemia and acidaemia.

Computer-assisted analysis of normal second trimester fetal heart rate patterns.

A software package for computer-assisted analysis of antenatal fetal heart rate (FHR) patterns has been commercially available from 1989. Reference ranges for the third trimester of pregnancy have been established. In order to obtain reference values for the second trimester, one hour FHR recordings were made between 20 and 29 weeks gestation in 77 women with uncomplicated pregnancies. There was a significant increase of (medium term) FHR variation and of the number of accelerations from 20 to 29 weeks (r = 0.48, p less than 0.01 and r = 0.34, p less than 0.01 respectively). The lower limit of normal FHR variation (mean--2 SD's) increased from 18 msec at 20 weeks to 28 msec at 28 weeks. Furthermore, a 30 minute recording appeared to be sufficient to obtain a reliable impression of FHR variation. Short term FHR variation, a measure of FHR variation that facilitates the identification of sinusoidal FHR patterns, also increased significantly between 20 and 29 weeks (r = 0.61, p less than 0.01). Delerations (greater than 20 beats/min and greater than or equal to 30 seconds) were present in 54% of the recordings and are a more or less common phenomenon at this age. It is concluded that during the second trimester FHR variation differs considerably from that in the third trimester. This should be taken into account in the interpretation of second trimester FHR records.

Relationship of fetal biophysical profile and blood gas values at cordocentesis in severely growth-retarded fetuses.

In 14 severely growth-retarded fetuses the biophysical profile score was analyzed in relation to blood PO2, pH, oxygen saturation, and oxygen content in samples obtained by cordocentesis. The data suggest that the biophysical profile score can predict the degree of fetal acidemia.

Changes in antepartum heart rate patterns with progressive deterioration of the fetal condition.

In this paper changes in antepartum fetal heart rate (FHR) patterns are described, that occur with progressive deterioration of the fetal condition. The data on the relationship between heart rate patterns and fetal blood gas and pH values are reviewed. A possible rank ordering is presented in which changes in FHR pattern, body movements and blood flow velocity wave form patterns occur with progressive deterioration of the fetal condition. It is concluded that in small-for-date fetuses changes in heart rate and movement patterns are rather late signs of impairment, coinciding with fetal hypoxaemia. In general, heart rate variation falls below the norm at the same time as decelerations occur; there are, however, large inter-fetal differences. In general, abnormal Doppler velocity wave form patterns precede the occurrence of heart rate decelerations. Their impact on the timing of delivery is, however, still uncertain. The advantages of a numerical analysis of FHR patterns include identification of fetuses with low FHR variation, precision of the actual fetal condition and (at early gestation) longitudinal follow-up of fetuses with abnormal heart rate patterns.