Neonatal periventricular leukomalacia preceded by fetal periventricular echodensity.

OBJECTIVE: The purpose of this prospective study is to verify whether fetal periventricular echodensity (PVE) precedes neonatal periventricular leukomalacia (PVL). METHODS: Fetal brains were studied with transvaginal scan in 63 high-risk fetuses from 17 to 32 weeks of pregnancy, PVE echogenicity was quantified with ultrasonic histogram, and neonatal brains and clinical courses were studied after birth. RESULTS: No fetal cystic PVL was found, instead, fetal PVE was detected in 42 fetuses. The quantified echogenicity value was higher in PVE than in normal brain. Four cases developed neonatal PVL among 28 preterm and 1 among 14 term births. Neonatal PVL developed in the 23 cases of persistent fetal PVE, whereas no neonatal PVL was found when fetal PVE was negative or disappeared. Cord compression signs were common in PVL cases. CONCLUSION: Neonatal PVL was preceded by antepartum persistent fetal PVE in the present study.

Analysis of fetal movements by Doppler actocardiogram and fetal B-mode imaging.

We have presented that fetal surveillance may be enhanced by use of the fetal actocardiogram and by computerized processing of fetal motion as well as fetal B-mode ultrasound imaging. Ultrasonic Doppler fetal actogram is a sensitive and objective method for detecting and recording fetal movements. Computer processing of the actograph output signals enables powerful, detailed, and convenient analysis of fetal physiologic phenomena. The actocardiogram is a useful measurement tool not only in fetal behavioral studies but also in evaluation of fetal well-being. It reduces false-positive, nonreactive NST and false-positive sinusoidal FHR pattern. It is a valuable tool to predict fetal distress. The results of intrapartum fetal monitoring are further improved by the antepartum application of the actocardiogram. Quantified fetal motion analysis is a useful, objective evaluation of the embryo and fetus. This method allows monitoring of changes in fetal movement, as well as frequency, amplitude, and duration. Furthermore, quantification of fetal motion enables evaluation of fetal behavior states and how these states relate to other measurements, such as changes in FHR. Numeric analysis of both fetal actogram and fetal motion from B-mode images is a promising application in the correlation of fetal activity or behavior with other fetal physiologic measurements.

Echogenicity of fetal lung and liver quantified by the grey-level histogram width.

Grey-level histogram width (GLHW) values of fetal lung and liver were studied in 52 healthy fetuses in 24 to 38 weeks of pregnancy, comparing them to the mean grey level (MGL), grey-level standard deviation (GLSD) and the coefficient of variation (GLCV). Fetal lung GLHW was larger in 30-38 weeks than at 24-29 weeks, but there was no change in liver GLHW. GLHW was smaller in fetal lung than in the liver in 24-29 weeks, with no difference in 30-38 weeks. The lung/liver GLHW ratios were less than 1 in 24-29 weeks, but they were 1 or more in 30-35 weeks. Both MGL of fetal lung and liver showed linear increases during pregnancy, but no difference was found between the two. Fetal lung GLSD tended to decrease during pregnancy. The GLCV values of fetal lung and liver decreased during pregnancy, and differed between 24-29 weeks and 30-38 weeks, whereas there was no difference between fetal lung and liver. The correlation coefficients of GLHW and MGL of fetal lung and liver to the weeks of pregnancy were moderate, and the coefficients of GLSD and GLCV to the weeks of pregnancy were small. In conclusion, quantitatively measured echogenicity of fetal lung increased in 30 or more weeks of pregnancy, and suggested antepartum changes of fetal lung tissue. The GLHW is reliable, because it was reproducible in various gain settings of various ultrasonic imaging devices. The MGL, GLSD and GLCV are less reliable, because the grey level varied by the gain changes among various machines.

Quantification of sonographic echogenicity with grey-level histogram width: a clinical tissue characterization.

Grey-level histogram width (GLHW) values obtained by common sonographic devices were large in echogenic image and small in less echoic parts. The Aloka UIP-100 computer system, SSD-680, and Toshiba SSA-270A sonographs showed GLHW values not significantly different when tested with RMI-412 phantom with the device contrast set at the lowest level. No influence on the GLHW value was observed by the changes of device gain, STC or image depth in the range of clinical practice. Device contrast control influenced the value. Although two sonographs showed significant differences from UIP-100, they were easily corrected by a small factor. Normal ranges of GLHW values of the placenta were obtained every 2 weeks, from 20 to 41 weeks, in 222 normal pregnancies measured by old scanners. GLHW values of normal pregnancies measured by the new Aloka and Toshiba machines were distributed within the normal ranges, and those of Grannum Grade III abnormally echogenic placenta were greater than the upper normal range. GLHW is a reproducible value among commercial ultrasonic devices, and the value is useful in clinical practice. Manual and automated GLHW values were identical.

Neural Network Computer Analysis of Fetal Heart Rate.

> Objective: A nonsubjective evaluation of intrapartum fetal heart rate (FHR) with a neural network (NNW) computer system and its clinical application. Methods: Eight simple FHR data were input into the NNW computer after 16-step normalizations. The computer was composed of 40 units in the input layer, 30 in intermediate layer, and 3 in the output layer, and the probabilities to be normal, suspicious, and pathological were obtained at the output. Before use, the computer was trained 10,000 times by 50-min teacher FHR data of 20 cases with known outcomes. The trained NNW computer was tested by FHRs of another 29 cases. The outcome probabilities in 15 min were calculated every 5 min in another 10 cases, and the bar graphs of the probabilities were displayed in sequence in the trendgrams. Results: The trained NNW computer was 100% accurate in the internal check; in the external check 86% of the results were evaluated correctly with the cardiotocogram, Apgar score, and umbilical arterial pH of the 29 test cases. The FHR scores of our conventional computer FHR analysis were higher in the suspicious and pathological groups than the normal group, and the fetal distress index was high in the pathological group. The trendgrams were simply accurate in typically normal or abnormal cases, transitory abnormal probabilities were shown in intermediate cases, and mixed suspicious and pathological probabilities suggested pathological outcome. Conclusions: The outcome probabilities and their trendgrams in the NNW FHR analysis are promising in objective decision making in the intrapartum stage.

MR angiography of cerebral vasospasm in preeclampsia.

Cerebral vasospasm was demonstrated with MR angiography in a patient with preeclampsia. MR angiography 5 days after the onset of symptoms clearly demonstrated diffuse intracranial vasospasm. The follow-up study confirmed the resolution of vasospasm successfully.

Ultrasound in fetal diagnosis and therapy.

Ultrasonic diagnosis is indispensable in perinatal medicine. The applications are; 1) diagnosis of early pregnancy, 2) diagnosis of fetal life, 3) diagnosis of pregnancy weeks by fetal crown rump length, 4) evaluation of fetal growth by biparietal diameter, femur length, abdominal size, or estimated fetal weight, 5) detection of early abnormalities in blighted ovum, fetal death, hydatidiform mole, ectopic pregnancy, etc., 6) diagnosis of fetal anomalies, e.g. anencephaly, hydrocephaly, neck hygraoma, diaphragmatic hernia, congenital heart disease, intestinal obstruction, renal anomalies, obstructive uropathy, etc., 7) diagnosis of fetal diseases, e.g. hydrops fetalis, 8) diagnosis of placenta previa, hydramnios, oligohydramnios, cord coiling, excessive cord twisting, 9) detection and prediction of fetal compromise by fetal and uterine blood flow velocity wave forms, 10) further precise diagnosis by transvaginal sonography, 11) interventional ultrasound in genetic diagnosis with amniocentesis and chorionic villi sampling, fetal blood sampling with cordocentesis, 12) detection of fetal hypoxia by ultrasonic fetal monitor, fetal actocardiogram, and ultrasonic Doppler flowmetry.

[The course of pregnancy in patients with cardiac disease].

The outcome of 240 pregnancies in 202 patients with cardiac disease, who delivered between Jan. 1982 and Dec. 1987 at the National Cardiovascular Center was analyzed. Ninety-six patients had congenital heart disease. Forty-two had acquired valvular heart disease, 83 had cardiac arrhythmia, 7 had aortitis syndrome, 7 had cardiomyopathy and 2 had secondary angina pectoris. There was one case of each of the following cardiac diseases: Primary pulmonary hypertension, Marfan's syndrome and pericarditis. Nineteen of the above lapsed into congestive heart failure and there were two cases of maternal death. One was a case of primary pulmonary hypertension and the other had had an aortic valve replaced with a Bjork-Shiley prosthesis because of rheumatic valve disease. Another 16 mothers had artificial preterm delivery at a gestational age of 30 weeks to 36 weeks to reduce the risk of congestive heart failure. There were 5 cases of IUFD, three of which were attributed to maternal cardiac disease and another to fetal failure. Neonatal congenital heart disease was found in 8 cases. The percentage of IUGR, excepting twin pregnancies, was 14.8%.

On a portable memory device for physical activities and informations of maternal perception.

The condition of patients must be known to attending doctors for adequate management of a disease, particularly of high risk pregnancy. For this purpose, we have developed a portable computerized disease condition memory device to record the physical activities with maternal perception of fetal movement and uterine condition in daily life, both at home and during work. This device taken out by the patient is a small battery-driven CMOS 8 bit computer system (size: 107 x 80 x 30 mm, 240 g) and is equipped with push-botton switches on the upper side and a mercury switch inside it. The time of maternal perception of fetal movement and uterine contraction are recorded by the patient pressing the corresponding switch. Meanwhile the mercury switch serves as a acceleration sensor and the physical activities were measured by counting ON-OFF actions of the mercury switch caused by her movements. Consequently, the device has recorded physical activities automatically by wearing this unit all day long. The continuously recordable time is more than two weeks. The evaluation about the sensitivity of physical activity measurement has indicated that the mercury switch sensor was well related to the oxygen consumption rate in rest and mild exercise. Using this device to five pregnant women, the data showed the quantitative difference in physical activities between rest in bed and normal home life, and daily changes could be clearly observed. From these results, the physical activities and the condition of the patient in daily life can be followed by this device.

An autopsy case of congenital complete heart block in a newly born of a mother with systemic lupus erythematosus.

An autopsy case of congenital atrioventricular (AV) heart block is described. A newborn infant of a mother with systemic lupus erythematosus died 10 h after birth. Autopsy revealed hematoxylin bodies in the AV node, central fibrous body, and fibrous annulus of the heart. Also, immunoglobulin G (IgG) localization in the hematoxylin bodies was demonstrated by an immunoperoxidase technique. It is suggested that IgG or immune complexes crossed the placenta and that the immune deposition directly injured the cardiac conduction system, causing AV block.

Changes in the umbilical venous blood flow of human fetus in labor.

In the present study, we intended to depict the changes occurring during labor in the fetal umbilical blood flow. Simultaneously, we also investigated the characteristics of the changes and their relation to the fetal heart rate patterns. In 15 human labors, the blood flow velocity in the intra-abdominal part of the umbilical vein was recorded continuously by the pulsed Doppler ultrasound technique. At the same time, direct fetal ECG and uterine contraction were monitored. The umbilical venous blood flow during the uterine contraction was equal to or lower than that between the uterine contractions. The maximum umbilical blood flow was decreased by 50% or more at variable deceleration and reduction of the umbilical venous blood flow was followed by a decrease in heart rate. Otherwise at late deceleration, the umbilical venous blood flow reduction was not so marked and biphasic pulsation became evident following the heart rate decrease. The present study has revealed that the umbilical venous blood flow shows characteristic patterns at variable deceleration and late deceleration.

Changes in venous flow and intra tracheal flow in fetal breathing movements.

Using pulsed Doppler ultrasound combined with a real-time B-mode image, changes in the central venous blood flow and tracheal fluid flow were recognized during fetal breathing movements. The blood flow in the umbilical vein was increased with fetal inspiration in which the abdominal wall of fetus moved inward, and decreased with expiration in which the abdominal wall moved outward. Velocity in the fetal vena cava revealed a complex blood flow, in accordance with both fetal cardiac motions and breathing movements. The tracheal flow velocity during fetal breathing was measured at a maximum of 40 cm s-1 and the flow volume was estimated at a maximum of 6 ml breath-1 in the matured fetus.

Management of fetal complete atrioventricular block.

Congenital atrioventricular block was diagnosed with B-mode and M-mode ultrasonography at the 30th week of gestation in a bradycardic fetus. Major anomalies were excluded and prenatal fetal well-being was monitored with daily B-mode and maternal perception of fetal movement to detect circulatory derangement at an early stage. Because of the sudden onset of circulatory failure, emergency Caesarean section was performed to save the otherwise normal fetus. Two days later, the infant developed ventricular fibrillation, for which surgical intervention was indicated. Pacemaking was effective in reestablishing the neonatal circulation.

[Studies on the measurement of uterine contraction by the impedance-variance of maternal abdominal wall (author's transl)].

An electronic system for the detection of uterine contractions by impedance measurement of the maternal abdominal wall, where the placenta attached to the anterior uterine wall confirmed by using B-mode ultrasonic method, was evaluated in 74 subjects. Simultaneous recordings of uterine contractive activity with conventional external recording system were made. Impedance recordings were evaluated and compared with the external recordings. The available evidence from this study indicated that 88.31% of uterine contractions were accurately detected and the onset, peak and end of each uterine contractions was reliable parameters of impedance measurement. The uterine contractions which seemed to be weaker in second trimester and difficult to record by the usage of external method were clearly detectable by the method. However on the place of the maternal abdomen where the placenta was not attached, impedance recordings did not show corresponding response with each uterine contractions. It was indicated that impedance recordings on the localization of the placenta mainly represented the change of intraplacental blood volume following by uterine contractions. The advantages of this method consisted in the patients comfort and easy application of the recording electrodes, but the usefulness of the method was limited to the cases of anterior localization of the placenta, namely 50% of the whole pregnant women.

[Studies on the measurement of fetal breathing movement by the impedance method (author's transl)].

Fetal breathing movements (FBM) were detected without any invasion by recordings of impedance (IMP) variance on the maternal abdominal wall, where the FBM were visible through the myometrium and maternal abdominal wall. FBM was clearly shown by the IMP method in some modification. This IMP recordings consisted in several elements of maternal respiration and pulsation, fetal movements, FBM, etc. FBM elements on IMP recordings appeared to be in clear spike waves and these were identified as the FBM. Considering of the result of fetal respirotachogram utilizing of IMP recordings, FBM did not seemed to be regular movements. Fetal "hiccup' movements were shown as large biphasic spike waves on IMP recordings. FBM were accurately recognized by the separation of the FBM elements from FBM-IMP recordings by utilizing of the analogical subtractive amplifier system. FBM-IMP signals from the data recorder was dealt with the fast Fourier transformation (FFT) utilizing by the mini-computer system and frequency analysis of them was carried out. From the results of FFT passing through the infinite impulse response digital band-pass filter system, the only FBM elements were separately obtained.