Perinatal outcome of twin pregnancies with one structurally affected fetus: a case-control study.

OBJECTIVE: To determine whether one structurally affected fetus of a twin pregnancy further increases the risk of preterm delivery and to compare perinatal morbidity and mortality in these pregnancies with twin gestations with structurally normal fetuses. STUDY DESIGN: The cases (n = 25) included all twin gestations diagnosed from 1991 to 1994 with a sonographically detected fetal anomaly and a structurally normal co-twin delivered after 24 completed weeks' gestation. The control group consisted of 547 twin gestations delivered during the study period with no sonographically detected structural anomalies in either twin. RESULTS: Compared with controls, pregnancies with a single anomalous fetus (cases) delivered at a significantly lower gestational age (mean +/- SD: 34.0 +/- 3.2 weeks versus 35.6 +/- 3.2 weeks; p = 0.019) and had a significantly increased preterm delivery rate (76.0% vs 55.4%; p = 0.042). There was no significant difference in the incidence of intraventricular hemorrhage or respiratory distress syndrome, yet the perinatal mortality (80.0/1000 vs 6.4/1000; p = 0.000) and the average nursery stay (45.5 +/- 43.3 days versus 17.0 +/- 24.0 days; p = 0.003) were significantly increased for cases compared with controls. In addition, a significantly greater birth weight discordancy (> or = 30%) was seen in cases compared with controls (32.0% versus 9.1%; p = 0.002). The normal co-twin did not show any significant difference in the perinatal outcome variables studied when compared with controls. CONCLUSION: Compared with structurally normal twin pairs, twin gestations with a single anomalous fetus are at a significantly increased risk for preterm delivery. In addition, the anomalous fetus, but not the structurally normal co-twin, has a significantly increased mortality rate and a longer nursery stay. Finally, despite the increased risk for preterm delivery in twin pregnancies with one anomalous fetus, it is the nature of the anomaly itself that dictates the perinatal outcome.

Severe preeclampsia remote from term: labor induction or elective cesarean delivery?

OBJECTIVES: The study's objectives were as follows: (1) to determine the rate of vaginal delivery after labor induction in severe preeclampsia remote from term and (2) to determine potential predictors of success. STUDY DESIGN: Retrospective chart review was conducted on live-born singleton pregnancies complicated by severe preeclampsia and delivered at 24 to 34 weeks' gestation from January 1, 1992, to December 31, 1996. Exclusion criteria included eclampsia, presence of labor or spontaneous rupture of membranes on admission, and complication of pregnancy by an ultrasonographically detected fetal congenital anomaly. Patients were divided into 3 groups: elective cesarean delivery without labor, cesarean delivery after labor induction, and vaginal delivery after labor induction. Statistical analyses included multiple logistic regression, the Student t test, the chi2 test, and the Mann-Whitney test. P 32 weeks' gestation. The most common indication for cesarean delivery after induction, in 50.7% of the cases, was nonreassuring fetal heart rate. The median Bishop score was significantly higher (3 vs 2, P =.004) and the total hospital stay was significantly shorter in the vaginal delivery after induction group than in the cesarean delivery after induction group. However, there were no significant differences between the 2 groups in use of cervical ripening agents, gestational age at delivery, birth weight, 5-minute Apgar score, or postpartum endometritis. After exclusion of cesarean deliveries performed for malpresentation, there was no statistically significant difference in classic incision rates between the elective cesarean delivery without labor and cesarean delivery after induction groups (13.6% vs 6.8%; P =.137). According to logistic regression analysis, only the Bishop score was significantly associated with a successful induction (odds ratio 1.38, 95% confidence interval 1.11-1.71). Gestational age reached marginal significance (odds ratio 1.30, 95% confidence interval 0.89-1.89). CONCLUSIONS: (1) Labor induction should be considered a reasonable option for patients with severe preeclampsia at

Spontaneous resolution of an isolated unilateral fetal pleural effusion: a case report.

Isolated pleural effusion is rare and occurs when varying degrees of fluid surround the fetal lung without concomitant hydrops. This article reports a case in which spontaneous resolution of an isolated fetal pleural effusion occurred four weeks following the third trimester sonographic diagnosis, without any morbidity or mortality to the fetus or neonate. The diagnosis and possible complications associated with fetal pleural effusions are also discussed, as well as a proposal for management when confronted with this entity.

The fetus with gastroschisis: impact of route of delivery and prenatal ultrasonography.

OBJECTIVES: Our purpose was (1) to assess the influence of delivery route on neonatal outcome in fetuses with gastroschisis and (2) to correlate ultrasonographic appearance of fetal bowel with immediate postnatal outcome. STUDY DESIGN: Forty-seven cases (1986 to 1994) were reviewed; three abortions and two stillbirths were excluded. Ultrasonographic appearance of fetal bowel (small bowel dilatation > 10 mm) was evaluated in 27 cases. RESULTS: Twenty-six infants (61.9%) were delivered vaginally and 16 (38.1%) by cesarean section (11 elective, 5 in labor). Delivery route was not significantly associated with indicators of neonatal outcome (rate of primary closure, postoperative complications, days of parenteral nutrition, days to oral feeding, hospital days, or mortality). When ultrasonographic appearance of fetal bowel was correlated with outcome, fetuses with prenatally dilated bowel had significantly more bowel edema at birth (p=0.038), longer operative time (p=0.013), and higher overall rate of postoperative complications (p=0.037). CONCLUSIONS: (1) Elective cesarean delivery does not improve neonatal outcome in infants with gastroschisis. (2) Abnormal ultrasonographic appearance of fetal bowel is associated with a more difficult repair and a higher overall incidence of postoperative complications.

Fetal pyelectasis: is it always "physiologic"?

OBJECTIVE: Our purpose was to determine the degree of fetal pyelectasis predictive of neonatal renal pathologic processes. STUDY DESIGN: Eighty-four cases of pyelectasis were identified during the study period (1989 through 1993). Fetuses with anteroposterior diameter of the renal pelvis > or = 4 mm before 33 weeks or > or = 7 mm after 33 weeks without caliectasis were included. Fetuses with an anteroposterior diameter of > 10 mm were excluded. Postnatal evaluation included renal sonogram, voiding cystourethrogram, and renal flow and function studies. RESULTS: Sixteen cases were excluded because of incomplete postnatal workup. Renal pathologic processes were found in 30 of 68 (44%) at birth; the most common were ureteropelvic junction obstruction (37%) and vesicoureteral reflux (33%). Only four cases required surgical intervention (13%), and the remaining 87% were managed conservatively. A normal urinary tract was found in 25% of the infants and the remaining 21 of 68 (31%) had regression of pyelectasis before birth. Fetuses with a dilated anteroposterior diameter > or = 8 mm after 28 weeks' gestation were found to have renal pathologic features in two of three of the cases, with sensitivity, specificity, and positive and negative predictive values of 87%, 41%, 66.7% and 70%, respectively. CONCLUSION: Fetuses with an anteroposterior diameter of the renal pelvis > or = 8 mm after 28 weeks' gestation require appropriate urologic evaluation after birth.

Prenatal diagnosis and therapy for a fetal hepatic vascular malformation.

BACKGROUND: Congenital hepatic arteriovenous malformations complicated by high-output heart failure and hematologic derangements are associated with up to 90% mortality. Prenatal diagnosis alerts the pediatrician to the need for early neonatal intervention. CASE: A fetal hepatic arteriovenous malformation with associated high-output cardiac failure was diagnosed at 29 weeks' gestation using real-time and color flow Doppler sonography. Hydrocortisone injected directly into the umbilical vein and the amniotic sac resulted in appreciable improvement in hemodynamic and hematologic indices. The pregnancy ended in a preterm delivery at 31 weeks with no evidence of heart failure at birth. CONCLUSION: The compromised preterm fetus with a hepatic arteriovenous malformation can be treated in utero, avoiding early emergency delivery.

Prenatal sonographic diagnosis of a third ventricle choroid plexus papilloma.

We report a case of fetal hydrocephalus secondary to a third ventricle choroid plexus papilloma detected by ultrasound at 33 weeks' gestation. The prenatal sonographic and colour flow Doppler findings of this rare fetal intracranial tumour are discussed.