Neonatal outcomes based on antenatal corticosteroid exposure time for infants delivered between 23 and 34 weeks gestation.

OBJECTIVE: To determine the minimal time interval required after antenatal corticosteroid treatment to see improvement in neonatal outcomes. STUDY DESIGN: A retrospective cohort analysis was performed on all women who delivered an infant between 23 0/7 weeks and 33 6/7 weeks gestational age from January 1, 2009 to August 31, 2013. Maternal data collected: maternal race, parity, mode of delivery, indication for delivery, infant birth weight, antenatal corticosteroid (ACS) administration, and time from ACS until delivery. Neonatal data collected: respiratory distress syndrome (RDS), intraventricular hemorrhage (IVH), necrotizing enterocolitis (NEC), sepsis, retinopathy of prematurity (ROP), intubation, surfactant administration, length of hospitalization, and mortality. RESULTS: Infants were grouped by ACS exposure time before delivery. Gestational age at delivery was similar between the groups. There was not a statisti- cally significant difference in the rate of RDS between the groups. Infants delivered 24 to 47 hours of ACS had the lowest rates of surfactant, intubation, and IVH. There appears to be a larger impact ofACS on infants delivered at 29 to 34 weeks vs. 23-28 weeks gestation. CONCLUSIONS: Improvement in neonatal outcomes are seen after any amount of ACS exposure but are generally most significant 24 to 47 hours after administration and between 29 to 34 weeks gestation.

Influence of gestational age and fetal heart rate on the fetal mechanical PR interval.

OBJECTIVE: The fetal mechanical PR interval obtained via pulsed Doppler has previously been demonstrated to correlate with electrocardiographic PR interval measured in the neonate. We sought to further analyze the influence of fetal heart rate and gestational age upon the fetal mechanical PR interval. METHODS: We searched our database for mechanical PR intervals, which were obtained during fetal echocardiography performed in our antenatal diagnostic unit. We included fetuses with a normal cardiac structural survey. The mechanical PR interval is measured from the A wave of the mitral valve to the beginning of ventricular systole corresponding to the opening of the aortic valve. Linear regression curves were generated to examine the correlation of mechanical PR interval with gestational age and fetal heart rate. Analysis of variance was used to compare the mean variation across three gestational age groups: 17-21.9 weeks (n = 24), 22-25.9 weeks (n = 52) and 26-38 weeks (n = 20). RESULTS: Mechanical PR intervals were measured in 96 fetuses with normal fetal echocardiography. The mechanical PR interval was 123.9 +/- 10.3 ms (mean +/- SD), with a range of 90-150 ms. Linear regression curves correlating mechanical PR interval with fetal heart rate and gestational age demonstrated a flat slope with R2 = 0.016, p = 0.22 and R2 = 0.0004, p = 0.85, respectively. The mechanical PR interval measured over the three gestational ages was as follows (mean +/- SD): 122.3 +/- 10.5 ms for 17-21.9 weeks; 125.0 +/- 9.6 ms for 22-25.9 weeks; and 123.1 +/- 11.9 ms for 26-38 weeks. Analysis of variance revealed no difference among the mechanical PR interval means measured over the three gestational age groups (p = 0.53). CONCLUSIONS: Fetal mechanical PR interval ranges from 90 to 150 ms in fetuses with sonographically normal fetal cardiac structure and rate. The mechanical PR interval appears to be independent of gestational age and fetal heart rate.

Cost analysis of Down syndrome screening in advanced maternal age.

OBJECTIVE: To analyze the potential cost and efficacy of Down syndrome screening in the population with advanced maternal age. METHODS: Three screening methods defining Down syndrome risk for women with advanced maternal age were analyzed: advanced maternal age; advanced maternal age and maternal serum triple screen; and advanced maternal age, maternal serum triple screen and genetic sonogram. Costs for all tests and procedures were estimated. Procedure-related loss for amniocentesis was assumed to be 1:200. Efficacy was defined as: number of amniocenteses performed, number of Down syndrome cases detected, procedure-related losses, Down syndrome cases detected per fetal loss, cost per Down syndrome case detected and total cost of screening. RESULTS: In 1999 in the USA, there were 530,610 women with advanced maternal age at 16 weeks' gestation carrying an estimated 4,043 fetuses with Down syndrome. Screening by maternal age alone would result in the 100% detection of Down syndrome cases, but would require over 530,000 amniocenteses and result in 2,653 procedure-related losses. Combining age with serum screen and genetic sonogram would detect 97.6% of Down syndrome cases, but would require only 119,791 amniocenteses and result in 599 procedure-related losses. The projected cost per Down syndrome case detected using age screening is 219,109 dollars versus 155,992 dollars using serum screen and genetic sonogram. CONCLUSIONS: The combination of advanced maternal age, maternal serum screen and genetic sonogram would result in the fewest procedure-related losses and lowest cost per Down syndrome case detected.

Is an isolated fetal cardiac echogenic focus an indication for fetal echocardiography?

OBJECTIVE: To determine whether the presence of an isolated fetal cardiac echogenic focus should be an indication for fetal echocardiography. METHODS: We reviewed our fetal echocardiography and obstetrics databases from January 1992 through July 1999. The study groups were formulated from patients referred for fetal echocardiography. Patients referred for echocardiography because of a single isolated fetal cardiac echogenic focus were compared with patients referred for other indications. The sensitivity, specificity, and positive and negative predictive values were calculated for an isolated echogenic focus as a marker for structural cardiac abnormalities as detected by fetal echocardiography. RESULTS: Of 10,406 fetuses seen for ultrasonography, 1908 had fetal echocardiography. Cardiac abnormalities were identified in 3.4% (65 of 1908) of the fetuses that had echocardiography. The prevalence of an isolated echogenic focus was 2.2% (230 of 10,406) and was the indication in 12.1% (230 of 1908) of our echocardiograms. Only 1 of the 230 fetuses with an isolated echogenic focus had a structural cardiac defect (membranous ventricular septal defect). An isolated echogenic focus as a marker for congenital cardiac defects resulted in sensitivity and specificity of 1.5% and 87.6%, respectively. The positive and negative predictive values were 0.4% and 96.2%, respectively The relative risk for an echogenic focus in predicting congenital cardiac defects was 0.11 (95% confidence interval, 0.02-0.82). CONCLUSIONS: An isolated fetal cardiac echogenic focus is not an efficacious marker for congenital cardiac defects. It should not be the sole indication for fetal echocardiography.

Irreversible maternal brain injury during pregnancy: a case report and review of the literature.

Maternal brain death or massive injury leading to persistent vegetative state during pregnancy is a rare event. Since 1979, 11 cases, including the current one, of irreversible maternal brain damage in pregnancy have been reported. In all but one, the pregnancies were prolonged with a goal of achieving delivery of a viable infant. Current advances in medicine and critical care enable today's physician to offer prolonged life-support to maximize the chances for survival in the neonate whose mother is technically brain dead. We present a case at our institution and review all previously published cases in the English literature for comparison as well as make management recommendations.

Efficacy of screening for fetal Down syndrome in the United States from 1974 to 1997.

OBJECTIVE: To estimate the 16-week prevalence of Down syndrome in the United States from 1974 to 1997 and to determine the efficacy of maternal age cutoffs and triple screens for detecting it antenatally. METHODS: Using natality statistics for the United States from 1974 to 1997 of maternal-age-specific live births to women 13-49 years old, we evaluated advanced maternal age (35-49 years at delivery) and the triple serum test (maternal serum alpha-fetoprotein, hCG, and unconjugated estriol) as screening tests for Down syndrome. Efficacy was evaluated using sensitivity, false-positive rate, positive predictive value, and likelihood ratio (likelihood ratio = sensitivity/false-positive rate). RESULTS: In 1974, the estimated second-trimester prevalence of Down syndrome was one in 740, but by 1997 that had increased to one in 504. The proportion of Down syndrome fetuses at 16 weeks' gestation in women 35-49 years old increased from 28.5% in 1974 to 47.3% in 1997. However, live births to women 35-49 years old increased more rapidly from 4.7% in 1974 to 12.6% in 1997. The likelihood ratio for maternal age to identify an affected pregnancy decreased during the study period and was substantially lower than that using the serum test. CONCLUSION: A maternal age cutoff of 35 years in the 1990s resulted in high false-positive rates and was less efficacious based on likelihood ratio and positive predictive value. Serum testing of all pregnant women would reduce the number of amniocenteses and decrease procedure-related losses.

Outcome of pregnancies complicated by ruptured membranes after genetic amniocentesis.

OBJECTIVE: We sought to compare perinatal outcomes of pregnancies complicated by preterm premature rupture of membranes after genetic amniocentesis with pregnancies complicated by spontaneous preterm premature rupture of membranes at a similar gestational age. STUDY DESIGN: A retrospective study was performed in which a computerized database was reviewed to identify all patients presenting to our institution with preterm premature rupture of membranes within 48 hours of a genetic amniocentesis from July 1988 to August 1999. Control subjects were matched for gestational age at preterm premature rupture of membranes. Patients were all managed expectantly. Outcomes were compiled from review of medical records. Descriptive statistics, the Student t test, and the chi(2) test were used, with P <.05 considered significant. RESULTS: During the study period, genetic amniocentesis was performed 1101 times. Eleven (1%) women presented within 48 hours with preterm premature rupture of membranes. The mean gestational age at the time of rupture was not different between the cases in which preterm premature rupture of membranes occurred after genetic amniocentesis compared with the control subjects in whom preterm premature rupture of membranes occurred spontaneously (16.5 weeks vs 17.6 weeks, respectively). Women with preterm premature rupture of membranes after amniocentesis experienced significantly longer latency periods (124 vs 28 days; P =.0001) and delivered at more advanced gestational ages (34.2 vs 21.6 weeks; P =.0002) than those with spontaneous preterm premature rupture of membranes. The perinatal survival rate was 91% in pregnancies complicated by preterm premature rupture of membranes after genetic amniocentesis compared with a rate of 9% in control subjects (P =.005). CONCLUSIONS: Pregnancies complicated by preterm premature rupture of membranes after genetic amniocentesis result in significantly better perinatal outcomes compared with pregnancies complicated by spontaneous preterm premature rupture of membranes at a similar gestational age. Expectant management should be considered in such cases.

Comprehensive fetal ultrasonographic growth measurements in triplet gestations.

OBJECTIVE: Our purpose was to create tables and graphs of ultrasonographically derived fetal growth parameters in longitudinally studied triplet gestations from a single center. STUDY DESIGN: All triplet pregnancies managed by our division from 1987 through 1998 were identified. All had first-trimester dating sonograms and complete obstetric sonograms obtained by means of 3.5- or 5.0-MHz curvilinear transducers with freeze-freeze capability and on-screen calipers. Sonograms to assess fetal growth were obtained every 2 to 4 weeks, from 16 to 18 weeks' gestation until delivery. Fetal parameters obtained with each sonogram included biparietal diameter; head circumference; bicerebellar diameter; abdominal circumference; femur, humerus, tibia, and fibula lengths; estimated fetal weight; and head circumference/abdominal circumference ratio. Regression analysis was performed with JMP and Cricket Graph software packages, and lines of best fit with 95% confidence intervals were generated. RESULTS: A total of 443 ultrasonographic examinations were performed for 33 triplet pregnancies (99 fetuses). Each had between 3 and 6 sonograms obtained, all between 16 and 35 weeks' gestation. Scatterplots of each of the fetal growth parameters against gestational age were created with regression lines of best fit and 95% confidence intervals. All growth parameters were dependent on gestational age. CONCLUSION: A comprehensive set of fetal growth measurements in triplets from the United States is now available and can be used to assess longitudinal fetal growth.

Rotational versus nonrotational forceps: maternal and neonatal outcomes.

OBJECTIVE: Our purpose was to evaluate maternal and neonatal morbidity associated with rotations performed with Leff forceps in comparison with nonrotational forceps deliveries. STUDY DESIGN: A review of 267 rotational and nonrotational forceps deliveries from August 1996 through February 1998 was performed. Multiple maternal and neonatal outcome measures were compared and results were analyzed by chi(2) with the Fisher exact test and the Student t test. RESULTS: One hundred sixty-three traditional low-forceps or outlet forceps deliveries were compared with 104 rotational forceps deliveries performed with Leff forceps. There were no significant differences between the 2 groups in maternal age, gestational age, gravidity, parity, total labor duration, birth weight, and Apgar scores. There were significantly lower rates of episiotomy, third- and fourth-degree lacerations, and sulcus lacerations in the rotation group, and the second stage of labor was also shorter. The neonatal intensive care unit admission rate was higher in the rotation group; however, none of the admissions were directly related to the mode of delivery. CONCLUSION: Rotational deliveries performed with Leff forceps are associated with less maternal morbidity and shorter second stage of labor than are deliveries performed with traditional forceps. Leff forceps are a safe option for rotation of the persistent occipitoposterior fetal position.

Transvaginal endometrial sonography in postmenopausal women taking tamoxifen.

OBJECTIVE: To evaluate sonographic measurements of endometrial thickness in postmenopausal women taking adjuvant tamoxifen therapy for breast cancer, and to correlate sonographic and pathologic findings to symptoms and duration of tamoxifen therapy. METHODS: Medical records and sonograms of 80 postmenopausal women treated for breast cancer with adjuvant tamoxifen therapy were reviewed retrospectively. Endometrial thickness was recorded as a single-layer thickness and considered abnormal when greater than 2.5 mm for postmenopausal women. Sonographic endometrial thickness was correlated to histologic findings, symptoms, and duration of tamoxifen therapy. RESULTS: Fifty-seven of 80 postmenopausal women (69%) had single-layer endometrial thicknesses of 2.5 mm or greater, measured by transvaginal sonography, and 55 of 57 had endometrial biopsies or dilatations and curettage. Biopsies detected 24 cases of abnormal endometria, including endometrial carcinoma (two), breast carcinoma metastatic to the endometrium (one), endometrial polyps (13), tubal metaplasia (three), and benign endometrial hyperplasia (five). Using a single-layer endometrial thickness greater than 2.5 mm by transvaginal ultrasound, 21 of 24 (87.5%) women with abnormal endometria were detected. Women with abnormal pathologic findings had a significantly thicker mean single-layer endometrial thickness than those with normal findings, 7 mm versus 4 mm (P < .01). Twelve women had postmenopausal bleeding, all of whom had a single-layer endometrial thickness greater than 2.5 mm on transvaginal sonography. CONCLUSION: With a sensitivity of detecting endometrial abnormalities of 84%, transvaginal sonography was useful for studying postmenopausal tamoxifen-treated women.

Relationship of amniotic fluid markers of intra-amniotic infection with histopathology in cases of preterm labor with intact membranes.

OBJECTIVE: To evaluate the correlation of amniotic fluid (AF) markers (AFMs) of intra-amniotic infection with histopathologic findings in cases of preterm labor with intact membranes, between 22 and 36 weeks' gestation. STUDY DESIGN: We reviewed the charts of patients admitted in preterm labor with intact membranes between January 1993 and December 1996. Those having amniocentesis were identified, and AFMs were compared with histopathology in patients who delivered within 48 hours of the amniocentesis. The AFMs evaluated were glucose, polymorphonuclear leukocytes, Gram stain, and culture. All placentae were reviewed by a single pathologist blinded to the AF findings. Histologic evidence of acute inflammation was defined by findings of both subchorial intervillositis and marginating choriodeciduitis. The sensitivities, specificities, and positive and negative predictive values of the various AFMs were calculated. RESULTS: Of 556 women with intact membranes presenting in preterm labor, 181 (32.6%) had amniocentesis and 88 delivered within 48 hours of the amniocentesis. Histopathologic chorioamnionitis was seen in 53 patients (60.2%). The findings (with their sensitivity, specificity, and positive and negative predictive values) were: polymorphonuclear leukocytes at > 10/high-power field (22.6%, 97.2%, 92.3%, and 46.1%), positive Gram stain (26.4%, 94.6%, 87.5%, and 47.3%), culture (28.3%, 92.1%, 83.3%, and 47.9%), and glucose of < 15 mg/dl (28.3%, 94.6%, 88.2%, and 47.9%), respectively. Using a receiver-operator characteristic curve for different level of AF glucose, a glucose level of < 20 mg/dl was the most sensitive AF predictor of histologic chorioamnionitis. CONCLUSION: Histopathologic evidence of chorioamnionitis was present in 60.2% of cases of preterm births due to preterm labor in women who at our institution were offered and accepted amniocentesis and subsequently delivered within 48 hours. AFMs may be useful predictors of histologic chorioamnionitis. The most efficient AFM for chorioamnionitis in this group of patients was glucose at < 20 mg/dl.

Clinical and ultrasonographic features of dextroposition of the fetal heart.

OBJECTIVE: Our purpose was to characterize the findings associated with dextroposition of the fetal heart. STUDY DESIGN: A fetal echocardiography database was retrospectively searched from January 1990 through December 1996 to identify all cases referred or diagnosed with dextroposition of the fetal heart. Dextroposition was defined as most of the normally connected fetal heart found on the right side of the fetal chest. Intracardiac and extracardiac fetal anomalies were reviewed. All available karyotypes and postnatal examinations were reviewed. RESULTS: During the study period 2882 fetal echocardiograms were performed, of which 297 (10.3%) were abnormal. Of these, 14 had dextroposition. Associated anomalies included atrioventricular canal (29%), diaphragmatic hernia (21%), and aneuploidy (14%). Isolated dextroposition with no other significant anomalies was seen in only 1 case. In another, no anomalies were noted except for suspected agenesis of 1 lobe of the right lung; karyotype and postnatal evaluation revealed no other abnormalities in both cases. CONCLUSIONS: Dextroposition of the fetal heart was seen in 0.5% of our fetal echocardiograms and was associated with significant anomalies in 86% of our cases. When diagnosed, a targeted ultrasonogram, fetal echocardiogram, and karyotype should be offered.

Management of parvovirus infection in pregnancy and outcomes of hydrops: a survey of members of the Society of Perinatal Obstetricians.

OBJECTIVE: Our purpose was to investigate the evaluation and management of parvovirus infection during pregnancy. STUDY DESIGN: Surveys were mailed to members of the Society of Perinatal Obstetricians residing in the United States and Canada in July 1997. They were asked about their evaluation and management of parvovirus infection, including whether they repeated and confirmed serologic studies, what their initial and follow-up evaluations included, whether they had had any cases of parvovirus-associated hydrops in the past 2 years, and if so, what were the management and outcomes of the hydropic fetuses. RESULTS: Surveys were mailed to 1623 members of the Society of Perinatal Obstetricians and 541 completed surveys were returned. Sixty-eight percent of the respondents repeated and confirmed serologic studies. Eighty-nine percent used ultrasonography in their initial management of pregnant patients with recent parvovirus infection, 7.5% used amniocentesis for polymerase chain reaction, and 2% used fetal blood sampling. The outcomes of the 539 cases of parvovirus-induced hydrops included spontaneous resolution in 34%, death without intrauterine transfusion in 30%, resolution after intrauterine transfusion in 29%, death after intrauterine transfusion in 6%, and pregnancy termination in 1%. Almost all cases of nonimmune hydrops reported occurred between 16 and 32 weeks. CONCLUSIONS: Approximately one third of the cases of parvovirus-induced nonimmune hydrops resolved spontaneously, whereas 83.5% of hydropic fetuses transfused survived.

Resolution of human parvovirus B19-induced nonimmune hydrops after intrauterine transfusion.

Our objective is to report our experience with cases of prolonged recovery from nonimmune hydrops secondary to human parvovirus B19 infection occurring after intrauterine transfusion. We reviewed cases referred to our unit over a 10 year period for exposure to parvovirus B19 infection. Those cases with serologic evidence of recent infection were identified. The cases requiring intrauterine transfusion were reviewed for demographic details, time of exposure, parvovirus B19 serology, gestational age at detection of nonimmune hydrops, number and results of fetal blood samples, duration from intrauterine transfusion to resolution of hydrops, and neonatal outcome. Of 38 cases identified through serologic evidence of recent parvovirus B19 infection, 35 (92.1%) did not develop hydrops, and these were followed by serial ultrasonography for 8 weeks from the time of exposure. Three cases (7.9%) developed hydrops and required intrauterine transfusion; in two the transfusion was intravascular and in one it was intraperitoneal. The mean duration from intrauterine transfusion to resolution of hydrops was 8 weeks 2 days. Pregnancy outcome in all cases was normal. In cases of nonimmune hydrops secondary to parvovirus B19 infection, resolution of the hydrops after intrauterine transfusion may take up to 12 weeks with a normal pregnancy outcome.

Long-term outcome of children following maternal human parvovirus B19 infection.

OBJECTIVE: To determine the long-term outcomes of children exposed in utero to maternal parvovirus B19 infection. METHODS: All pregnant women with serologic evidence of recent parvovirus B19 infection and a comparison group with serologic evidence of past infection from January 1988 to December 1994 were sent questionnaires or contacted by phone about the health and development of their children. Information requested included: pregnancy complications, date of delivery, birth weight, sex, birth defects, need for special care, significant health problems, and developmental delays. All women had serology done at either the Centers for Disease Control and Prevention or the virology laboratory of the Connecticut Department of Health. The data were analyzed using descriptive statistics, chi2 analysis with Fisher exact test, or Student t test in appropriate cases. P < .05 was considered significant. RESULTS: Outcome information was obtained from 113 of 117 immunoglobulin-M positive women. The 113 respondents had 103 term singletons, two sets of twins (of which one neonate died of complications of prematurity), one hydropic stillborn, four spontaneous abortions, and one ectopic pregnancy. The mean gestational age at time of exposure was 15.6 weeks. The median age of the liveborn infants in study and comparison groups was 4 years. Eight of the 108 (7.3%) surviving children, one set of twins (exposed at 27 weeks), and six singletons (exposed at 7, 8, 9, 20, 27, and 35 weeks) had developmental delays in speech, language, information processing, and attention. Outcomes were obtained for 99 of 110 patients with past infection; they had 83 liveborn singletons, five sets of twins, two stillborns, and five spontaneous abortions. Seven of the 93 (7.5%) children had developmental delays, similar to the study group. Post-hoc power analysis revealed that 712 infected patients would be needed to find a twofold difference in the risk of abnormal neurologic development; our study had 30% power to find such a difference. CONCLUSION: There is no apparent increase in the frequency of developmental delays in children with exposure in utero to parvovirus, but larger studies are needed.

Monoamniotic twins: improved perinatal survival with accurate prenatal diagnosis and antenatal fetal surveillance.

OBJECTIVE: Our goal was to report our 10-year experience with monoamniotic twins and to compare that experience with cases reported in the literature. STUDY DESIGN: Records of all monoamniotic twin pregnancies managed at the University of Connecticut Health Center from March 1986 to August 1996 were reviewed. A MEDLINE search from January 1966 to August 1996 was performed, and each report was screened for accuracy of diagnosis. Only cases with umbilical cord entanglement of nonconjoined like-sex twins, the obstetrician's confirmation at delivery, or pathologic confirmation of monoamniotic placentation were included. Data collected were as follows: birth outcome, gestational age at delivery, birth weight, gender, Apgar scores, hematocrit, cord knotting, and neonatal complications. Cases from the literature were divided into those with prenatal diagnosis and those without. RESULTS: Thirteen monoamniotic pregnancies resulting in 26 infants who were born alive were managed at our center. The average gestational age at diagnosis was 16.3 weeks. All had antenatal fetal surveillance including serial sonograms and nonstress tests. The average gestational age and birth weight at delivery were 32.9 weeks and 1669 gm, respectively. Cord entanglement was noted in all cases, with knotting in 8 of 13. Two pairs of 26 newborns had evidence of twin-twin transfusion syndrome. Eight of 13 monoamniotic pregnancies were delivered because of nonreassuring results of nonstress test, two because of preterm labor, two electively because of lung maturity, and one because of intrauterine growth restriction. Two of the 26 infants died in the neonatal period, one of congenital heart disease and one of sepsis and asphyxia. The MEDLINE search revealed 96 articles with a total of 202 sets of monoamniotic twins. Comparison of cases (13 sets) with the historic control group without prenatal diagnosis (77 sets) showed a 71% reduction in relative risk of perinatal mortality. CONCLUSIONS: With accurate prenatal diagnosis, intensive fetal surveillance, and appropriately timed delivery, perinatal survival of monoamniotic twins is improved; it was 92% in this series.

A randomized clinical trial comparing misoprostol with prostaglandin E2 gel for preinduction cervical ripening.

OBJECTIVE: Our purpose was to perform a randomized trial comparing intravaginal misoprostol to intravaginal prostaglandin E2 gel for preinduction cervical ripening evaluating efficacy and side effects. STUDY DESIGN: Seventy-five women seen for induction of labor were randomized to receive 100 micrograms of intravaginal misoprostol or 5 mg of pharmacy-prepared intravaginal prostaglandin E2 gel for cervical ripening before oxytocin induction. Six hours after placement of the study agent, patients were given oxytocin if they were not in labor. The primary outcome measure was induction-to-delivery time; secondary measures were change in Bishop score, delivery mode, and side effects. Results were analyzed by the Student t test and Fisher's exact test, with p < 0.05 considered significant. RESULTS: There was no difference in the incidence of primiparity or the median initial Bishop score between the two study groups. The mean time to delivery and the need for oxytocin was significantly less for subjects receiving misoprostol. There was no difference in the incidence of uterine hyperstimulation syndrome or cesarean delivery between the groups. CONCLUSIONS: This randomized clinical trial indicates that misoprostol is efficacious for preinduction cervical ripening. Misoprostol use resulted in a significantly shorter induction-to-delivery time compared with prostaglandin E2 gel use. The side effects associated with misoprostol may be dose related, and further studies to identify the optimum dosage and interval are needed.

Late prenatal ultrasound features of hydrometrocolpos secondary to cloacal anomaly: case reports and review of the literature.

Cloacal anomalies are extremely rare and have variable presentations. Prenatal diagnosis can be difficult especially if they present in late gestation. Here we present two cases diagnosed in the late third trimester and review the literature regarding prenatal diagnosis of cloacal anomalies.

Iliac wing angle as a marker for trisomy 21 in the second trimester.

OBJECTIVE: To evaluate the fetal iliac wing angle in detecting trisomy 21 in the second trimester of pregnancy. METHODS: Using an axial view of the fetal pelvis, the angle between the right and left iliac wings (iliac wing angle) was measured ultrasonographically at the time of the second-trimester ultrasound or genetic amniocentesis in 377 singleton fetuses. Trisomy 21 was diagnosed by karyotype results from the amniocentesis or newborn examination with karyotype if trisomy 21 was suspected based on phenotypic features. Sensitivity, specificity, and positive (PPV) and negative predictive values (NPV) were calculated using multiple cutoff points. A receiver operating characteristic (ROC) curve was used to identify the optimum iliac wing angle. Descriptive statistics and Student t test were utilized for analyses with a P of less than .05 considered significant. RESULTS: The average gestational age was 18.8 weeks (range 13-32). Karyotypes were available in 128 fetuses. The overall prevalence of trisomy 21 was 11 of 377 (2.9%). The mean (+/-standard deviation) iliac wing angle in the normal fetuses was 68.2 degrees (+/-15.4 degrees) and 98.5 degrees (+/-11.3 degrees) in fetuses with trisomy 21 (P < .001). Using an ROC-derived absolute cutoff of 90 degrees, an abnormal iliac wing angle had sensitivity of 90.9% (ten of 11), specificity of 94.5% (346 of 366), NPV of 99.7% (346 of 347), and PPV of 33.3% (ten of 30) to detect trisomy 21. CONCLUSION: Fetuses with trisomy 21 have greater iliac wing angles than do normal fetuses. Using an ROC-derived absolute cutoff of 90 degrees, we could detect 90.9% of fetuses with trisomy 21 with a PPV of 33% in our high-risk population. These findings suggest that iliac wing angle is a useful marker in antenatal screening for trisomy 21.

Second-trimester abortion by intramuscular 15-methyl-prostaglandin F2 alpha or intravaginal prostaglandin E2 suppositories: a randomized trial.

OBJECTIVE: To compare intramuscular (IM) prostaglandin 15 methyl-F2 alpha (15M-PGF2 alpha) with prostaglandin E2 (PGE2) vaginal suppositories for second-trimester abortion in terms of efficacy and side effects. METHODS: Fifty-one women were randomized to receive either 15M-PGF2 alpha IM injections or PGE2 intravaginal suppositories for second-trimester abortion. Efficacy and side effects of the two agents were analyzed by two-tailed t tests, chi 2 analysis with Fisher exact test, and survival analysis. RESULTS: The mean times to rupture of membranes, delivery of fetus, and delivery of placenta were significantly less for women receiving PGE2 vaginal suppositories. The cumulative abortion rate after 24 hours for the PGE2 group was 96%, compared with 69% for the 15M-PGF2 alpha group. Although there were few differences in side effects, the 15M-PGF2 alpha group had significantly fewer headaches, fevers, and chills. CONCLUSION: Intravaginal PGE2 is superior to IM 15M-PGF2 alpha for second-trimester abortion.