Medical and ethical considerations in twin pregnancies discordant for serious cardiac disease.

OBJECTIVE: Prenatal ultrasound has led to the early diagnosis of major anomalies. However, the ready availability of this technology has led to increasing challenges for physicians counseling affected parents, which is all the more difficult in a twin pregnancy with only one affected fetus. This paper reviews the medical and ethical considerations in twin pregnancies discordant for a serious cardiac condition. STUDY DESIGN: Six recent twin pregnancies discordant for a serious cardiac condition and their outcomes are presented. Options considered in the management of the pregnancy were to continue or terminate the pregnancy, selectively terminate the affected twin or to decide whether to treat the affected twin once delivered. An approach to decision making in such situations has been formulated after critical analysis of the factors involved. RESULTS: Four of the six pregnancies were monochorionic twins. Two sets of parents decided to terminate the pregnancy. In the four that continued, two opted for the affected twin to be appropriately managed once delivered. A further two considered selective termination but opted to continue the pregnancy because of the risk of premature labor and/or cerebral hypoxia following such intervention. They sought a commitment, however, that they be given the option whether to treat the affected twin following delivery. Eventually both elected to have their babies treated, one of whom died in the postoperative period. DISCUSSION: Medical considerations included the risks of continuation of the pregnancy for the mother and her twins, the safety of termination (total or selective), and the risks to the unaffected fetus. Ethical issues revolved around concepts of autonomy, beneficence and justice from the standpoint of the family and the twins. The gestation and the viability of the twins played an important role in decision making and approaches, taking into account the local legal and other considerations. CONCLUSION: Attention is drawn to the complexities of the issues involved in twin pregnancies complicated by a serious cardiac condition in one of the twins. Optimal counseling requires sound clinical knowledge about the medical risks to the mother and her twins, and a clear understanding of the key ethical considerations. Such an approach will assist parents in their very difficult decision making.

Fetal cardiac diagnosis and its influence on the pregnancy and newborn--a tertiary centre experience.

OBJECTIVES: To evaluate the impact of an abnormal fetal cardiac scan on the management of the pregnancy and the outcome of the newborn. METHODS: We reviewed all pregnancies that were referred to the Fetal Cardiac Unit for assessment to determine if the finding of a cardiac abnormality influenced the pregnancy and fetus, timing and mode of delivery, the treatment and outcome of the newborn. Diagnoses were confirmed by echocardiography following the baby's delivery. RESULTS: Between January 2005 and July 2006, there were 251 detailed fetal cardiac scans carried out on at risk pregnancies or those with suspected abnormal scans in 127 fetuses. Seven of the 92 mothers with abnormal fetal cardiac scans opted for termination. Two were successfully treated during the pregnancy for hydrops fetalis arising from a tachyarrhythmia. One was induced early because of deterioration of fetal well-being and increasing cardiac size. Twenty-six infants required a prostaglandin infusion prior to surgery. Two required intensive care for associated malformations. There were 24 survivors following complex surgery, and 2 deaths. Two infants with severe tricuspid valve incompetence from a dysplastic valve died, one associated with a septicaemia and the other where surgery was delayed because of prematurity and low birth weight. There was no maternal morbidity or mortality. CONCLUSIONS: Early detection of fetal cardiac malformation allows for careful counselling of the parents, ongoing antenatal review with a planned site and timing of delivery, and anticipatory postnatal care for optimum outcomes. The importance of careful screening is emphasized to allow for referral of mothers with potentially abnormal scans to an appropriate tertiary centre for confirmation and management.

The effect of image size on screen-positive rates for nuchal translucency screening.

It has been shown previously that the absolute measurement of nuchal translucency (NT) thickness, one of the most effective screening tests for fetal Down syndrome, significantly decreases with increasing image size. We undertook a prospective study to assess whether this effect materially alters the NT-derived risk estimation for fetal Down syndrome. In 350 women, NT was measured at both 100 and 200% image sizes. The median NT measurement at 200% was 8% smaller than at 100%. The screen-positive rates at 100 and 200% image sizes were 5.1% (18/350) and 2.3% (8/350), respectively (P= 0.048). Altering the image magnification settings is likely to decrease the sensitivity of NT-derived Down syndrome risk estimation. Further study is required to test the effect of our finding on the sensitivity of NT screening and to assess whether adjustments in gain settings mitigate the effect.

Acoustic streaming: a new technique for assessing adnexal cysts.

OBJECTIVES: To determine whether acoustic streaming has clinical value in the differentiation between various ovarian and adnexal cysts. METHODS: We assessed 29 adnexal cysts, for which pathological diagnosis was available, for the presence of acoustic streaming during B-mode and color sonographic evaluation. RESULTS: Acoustic streaming was detected in 15 (52%) of the cysts. The most common cyst, endometrioma (n = 7), did not exhibit acoustic streaming in any case, while of the remaining 22 cysts, 15 exhibited acoustic streaming (P = 0.0017). Dermoid cysts exhibited acoustic streaming in two of six (33%) cases. In addition acoustic streaming was noted in two of two (100%) hemorrhagic cysts, eight of ten (80%) cystadenomas, two of three (67%) malignant cysts and in the one abscess. CONCLUSIONS: Acoustic streaming is the first sonographic feature that may be able to completely exclude endometrioma as a possible diagnosis for an adnexal cyst.

The utilisation of nuchal translucency as a prenatal marker of Down syndrome, 1993-1999.

A sample of 6,038 obstetric ultrasound referrals and reports between January 1993 and June 1999 in a single Melbourne private ultrasound practice was reviewed to determine whether the referral and reporting pattern for nuchal translucency (NT) measurement has changed. The proportion of both 10-14 week ultrasound scans and mid trimester fetal anatomy scan referrals increased significantly over the study period (p < 0.001 and p < 0.001, respectively). There was also a significant increase in NT reporting and the number of specific referrals for an NT measurement over the study period (p = 0.01 and p < 0.001, respectively). If current trends continue it is likely that the 10-14 week scan for NT measurement will become a routine component of antenatal care. Therefore, as a matter of urgency, it is imperative that the best and most cost-effective screening strategy for Down syndrome in an Australian population is defined.

Antenatal intestinal vascular accident with subsequent small bowel atresia: case report.

A woman was referred at 25 weeks' gestation with decreased fetal movements. Ultrasound revealed a large solid fetal abdominal mass and gross fetal ascites. Amniocentesis and viral titers were normal. On subsequent ultrasound examinations, the mass and ascites slowly disappeared, but a small bowel obstruction developed. Spontaneous labor occurred at 35 weeks and the child was born with a distended abdomen. At laparotomy there was type 3 jejunal atresia, indicating that the fetal mass and ascites were secondary to this antenatal small bowel ischemia.

Correlation between nuchal thickness and abnormal karyotype in first trimester fetuses.

OBJECTIVE: To evaluate the accuracy of ultrasound measurement of nuchal thickness in first trimester fetuses for predicting fetal karyotype. DESIGN: A prospective study of the nuchal thickness of fetuses measured during an ultrasound examination in all women undergoing first trimester chorionic villus sampling (CVS). SETTING: Two major public hospitals and two associated private practices between 7 September 1993 and 6 September 1994. PARTICIPANTS: Pregnant women with various indications for CVS (in 82% because of maternal age). RESULTS: 1306 women underwent CVS, including 11 with twin pregnancies: 1317 fetuses were tested. Karyotype results were obtained for 1312 fetuses: 41 (3.1%) had an abnormal karyotype, and 20 of these (49%) had a nuchal thickness measurement of 3 mm or more, compared with 44 (3.5%) of the 1271 fetuses with a normal karyotype. Of the 21 fetuses shown to have trisomy 21, 12 would have been detected if a nuchal thickness of 3 mm or more had been used as an indicator, giving a sensitivity of 57%. Nuchal thickness measurements of 1 or 2 mm excluded trisomy 21 with a negative predictive value of 99.3%. Fetuses with moderate nuchal thickening, normal karyotype and no other problems noted on the initial ultrasound scan had neonatal outcomes similar to those in the general obstetric population. CONCLUSION: Nuchal thickening in the first trimester (10 weeks on) of pregnancy in a high risk population is a powerful indicator of increased risk of aneuploidy.

Severe urethral obstruction diagnosed at 14 weeks' gestation: variability of outcome with and without drainage.

We present 3 case reports to illustrate the variability of outcome of severe fetal posterior urethral obstruction. Two of the described cases support the view that early in-utero decompression of an obstructed fetal urinary system into the amniotic cavity, in the selected patient, will allow adequate lung development and will prevent the development of severe renal dysplasia. It will not prevent the abdominal wall deformity of the prune belly syndrome. The evidence suggests that to allow maximum time for lung development and to prevent increasing renal dysplasia, drainage should be performed before 18 weeks of gestation. To obtain maximum effect, this drainage should continue until at least 32-33 weeks' gestation, so that the possible respiratory problems of prematurity would not be severe enough to compound the degree of lung hypoplasia which might be present. Case 3 supports our view that an endoscopic approach to in-utero drainage of the urinary tract has the advantage of achieving drainage with minimal risk to both mother and fetus.

In utero repair of diaphragmatic hernia.

This report describes the first in utero repair of diaphragmatic hernia in Australia. The patient was a 32 year old woman with major infertility problems who was diagnosed at 15 weeks gestation as having an infant with diaphragmatic hernia. After extensive consideration and counselling the parents requested in utero repair. This was performed at 28 weeks gestation and was technically successful, but the infant was found to be dead after uterine closure. The mother has subsequently been delivered of normal twins at term by Caesarean section. In utero repair of diaphragmatic hernia requires a high degree of team work, is technically demanding and has major ethical implications. It should be restricted to nationally designated units.

An open study of luteinizing hormone releasing hormone agonists in infertile women with uterine fibroids.

Twenty infertile women with fibroids were treated with luteinizing hormone releasing hormone agonists (LHRHa) to investigate if the use of these drugs, both with and without myomectomy, was effective in contributing to pregnancy in these women. All women had fibroids as their sole cause for infertility. Seven women conceived within 1 year of myomectomy or LHRHa treatment alone without myomectomy. The overall pregnancy rate was 36% and the postmyomectomy pregnancy rate was 50%. Initial fibroid size and extent of fibroid shrinkage on LHRHa therapy made no difference to the subsequent pregnancy rate. We also found no significant interaction between the number of fibroids present and the effect of myomectomy on the proportion of pregnancies. We conclude that the fertility enhancing value of myomectomy in otherwise idiopathic infertility is confirmed, and that the use of LHRHa premyomectomy in infertile women needs to be investigated in randomized controlled trials to assess its value as a preoperative therapy.

Clinical predictors for buserelin acetate treatment of uterine fibroids: a prospective study of 40 women.

Buserelin acetate, a luteinizing hormone-releasing hormone agonist, is known to be effective in the shrinkage of uterine fibroids. A prospective trial was undertaken (1) to compare the efficacy of intranasal (IN) and subcutaneous (SC) administration of buserelin acetate and (2) to assess if tumor regression correlated with fibroid size and/or patient age. Forty patients were randomly allocated to receive 6 months of either IN buserelin acetate (n = 21) or SC buserelin acetate (n = 19). Four patients did not complete the study and were excluded from statistical analysis. Fibroid regression occurred in all 36 patients. Overall regression to 66% or less of the initial fibroid volume occurred in 70% of subjects. There was no significant difference in fibroid shrinkage between the two administration routes. A significant positive correlation was found between initial fibroid size and subsequent fibroid regression, with larger tumors being more likely to shrink than smaller fibroids. No correlation was found between the patient's age and the extent of fibroid regression.

A case of multiple (5) ectopic pregnancies, ultimately resulting in a twin pregnancy after in vitro fertilization and embryo transfer.

The history of a woman with anovulation, tubal disease and 5 ectopic pregnancies is presented. She finally succeeded in having a family by conceiving twins in her eighth attempt at in vitro fertilization.

A comparison of vaginal ultrasonic-guided and laparoscopic retrieval of oocytes for in vitro fertilization.

A retrospective analysis was undertaken to compare the less invasive technique of vaginal ultrasonic-guided oocyte retrieval with the standard laparoscopic technique. We have shown that the outcome of the transvaginal technique with respect to oocytes harvested, fertilization rate, and pregnancy rate is comparable with the laparoscopy technique. We have also shown that 9 clinicians with little previous expertise in ultrasound have been able to incorporate this technique into a busy and successful in vitro fertilization unit.

Single dose extra-amniotic prostaglandin gel for midtrimester termination of pregnancy.

The efficacy of a single dose of prostaglandin F2 alpha gel instilled into the extra-amniotic space to induce termination of pregnancy in the second trimester has been assessed and compared with intra-amniotic prostaglandin F2 alpha and with an extra-amniotic infusion of prostaglandin F2 alpha combined with intravenous oxytocin. There was no significant difference between the methods in time taken to abortion, incidence of retained placenta, need for blood transfusion, or rate of sepsis. Single dose extra-amniotic prostaglandin gel is recommended as a safe, effective, and convenient method of midtrimester termination of pregnancy.

PIP: The efficacy of giving single-dose (40 mg) prostaglandin F2 alpha (PGF2a) in viscous gel instilled extraamniotically for pregnancy termination was compared with the use of intraamniotic injection of PGF2a and with extraamniotic infusion of PGF2a combined with intravenous oxytocin. Pregnancy induction occurred in second trimester patients. The 3 patient groups had no significant differences in age, gestation, or parity. There were no statistical differences in parameters measured, including time to abortion and side effects. Although more cases had aborted by 24 hours in the extramniotic PGF2a gel group, this was not statistically significant. Side effects encountered, but still not enough times to draw significant associations, were retention of placenta, gastrointestinal effects, need for blood transfusion, and sepsis. Because PGE2 is not available in Australia, these authors advocate the use of a single extraamniotic dose of PGF2a for pregnancy termination in the second trimester.

A case of benign intracranial hypertension in pregnancy.

We describe a 30-year-old patient who developed benign intracranial hypertension at 34 weeks in her second pregnancy and was treated both medically and by decompression of the perioptic meninges; her visual symptoms and signs remained static and she was delivered at 35 weeks by Caesarean section for poor progress in an induced labour.

Continuous measurement of tissue pH in the human fetal scalp.

A method for continuous measurement of scalp tissue pH is described. The tissue pH probe was found to be robust and values for tissue pH were close to those for scalp blood pH. Combining the pH and fetal heart fate (FHR) electrodes in the one mechanical assembly facilitated application to the fetal scalp in early labour but the combined assembly electrode was found to have some disadvantages and manufacture of a separate tissue PH electrode is recommended. Continuous monitoring of scalp tissue pH enables closer study of the physiological basis of changes in fetal acid base status and should prove useful to the obstetrician in management of high risk pregnancies during labour.