Outcomes associated with fetal hepatobiliary cysts: systematic review and meta-analysis.

OBJECTIVE: To explore the outcomes associated with fetal hepatobiliary cysts. METHODS: MEDLINE and EMBASE were searched for studies reporting on outcomes of fetal hepatobiliary cysts. Outcomes observed were resolution/reduction and increase in cyst size, associated congenital anomalies of the biliary tract and liver, abnormal postnatal liver function tests, clinical symptoms, need for surgery, postsurgical complications and predictive accuracy of prenatal ultrasound in identifying correctly hepatobiliary cysts. Meta-analysis of proportions was used to analyze the data. RESULTS: The search identified 1498 articles, and 22 studies (252 fetuses) were included in the systematic review. For fetal hepatic cysts, resolution or reduction in cyst size either pre- or postnatally occurred in 59.3% (95% CI, 30.9-84.7%) of cases, while an increase in cyst size occurred in 8.7% (95% CI, 1.1-22.4%). No case of hepatic cyst had associated malformations of the biliary tract at birth. Clinical symptoms occurred in 14.8% (95% CI, 6.3-26.1%) of cases and, in 5.4% (95% CI, 0.9-13.6%), they were related to the presence of bile obstruction due to compression of the cyst on the biliary tract. No case of hepatic cyst had abnormal liver function at birth. For fetal biliary cysts, resolution or reduction in cyst size occurred in 8.7% (95% CI, 2.7-17.5%) of cases and an increase in size occurred in 34.4% (95% CI, 20.5-49.8%). Congenital anomalies of the biliary tract and liver, such as fibrosis, occurred in 21.5% (95% CI, 10.2-35.6%) and 17.4% (95% CI, 5.4-34.4%) of cases, respectively. 57.3% (95% CI, 33.9-79.0%) of cases showed impairment in liver function after birth, while 55.0% (95% CI, 37.5-71.9%) showed clinical symptoms, mainly due to bile obstruction (47.9% (95% CI, 29.4-66.7%)). Postsurgical complications occurred in 10.9% (95% CI, 3.7-21.3%) of operated cases. Risk assessment according to different cut-offs of cyst size could not be performed in view of the very small number of included studies. CONCLUSIONS: Fetal hepatic cysts are benign, with a low likelihood of associated anomalies of the hepatobiliary tract, abnormal liver function or clinical symptoms. Congenital biliary cysts are associated with a high rate of progression, abnormal liver function after birth and clinical symptoms. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Diffusion tensor imaging of subependymal heterotopia.

A magnetic resonance (MR) diffusion tensor imaging (DTI) study was performed in a newborn with bilateral subependymal heterotopia (SE). White matter fractional anisotropy (FA), axial diffusivity (AD) and radial diffusivity (RD) were compared to values obtained in four newborns with moderate perinatal asphyxia and normal MRI findings. The reduction of FA and increase of AD and RD in the newborn with SE were the in vivo late expression of alterations in the intermediate zone, with an underlying arrest of neuronal migration.

Ultrasound prenatal diagnosis of a lateral facial cleft (Tessier number 7).

Lateral facial clefting may occur as an isolated phenomenon or in association with other disorders. It may originate from a failed penetration of ectomesenchyme between the developing maxillary and mandibular prominences, but disruptive factors may also occur in a proportion of cases. The frequency of this abnormality is estimated as 1 in 50 000-175 000 live births. We describe a case of isolated symmetrical lateral facial cleft (number 7 according to the Tessier classification) diagnosed prenatally on ultrasound examination at 26 weeks of gestation.

The effect of antenatal steroid administration on the fetal response to vibroacoustic stimulation.

BACKGROUND: Betamethasone transiently suppresses multiple fetal biophysical activities, including breathing movements, limb and trunk movements, heart rate variability, and heart rate accelerations. Unnecessary iatrogenic delivery of preterm fetuses due to the false diagnosis of fetal compromise has been described in this setting. The sonographically observed startle response of the fetus to vibroacoustic stimulation has been described as another modality to provide reassurance about fetal well-being. It is unknown, however, whether the startle response is also suppressed by betamethasone. The purpose of this study was to examine the effect of betamethasone on this biophysical parameter. METHODS: A prospective cohort study. Vibroacoustic stimulation was applied to the maternal abdomen and fetal movement responses were sonographically observed prior to (0 hours), 48 hours after, and 96 hours after betamethasone administration. We recorded the presence or absence of the fetal startle response, and, if a response was present, graded semi-quantitatively the intensity of the movements (vigorous versus sluggish). RESULTS: Twenty-two of 26 fetuses (84.6%) displayed a vigorous vibroacoustic startle response prior to betamethasone administration, in comparison to three of 26 fetuses (11.5%) at 48 hours after exposure (p<0.0001). Eleven fetuses and eight fetuses displayed no startle response at all (p<0.0005), or a sluggish response only (p<0.0005) at 48 hours, respectively. At 96 hours after betamethasone exposure, no differences in the number of fetuses with a vigorous, sluggish, or absent response were observed in comparison to 0 hours. Stratification of cases by gestational age groups of 28-30 weeks versus 31-34 weeks showed similar response patterns. CONCLUSION: Antenatal betamethasone exposure transiently suppresses the sonographically observed fetal startle response to vibroacoustic stimulation. Accordingly, this modality cannot be used for the ascertainment of fetal well-being of steroid exposed fetuses. Betamethasone seems to suppress central nervous system dependent biophysical activities. including the brain-stem dependent vibroacoustic startle reflex.

Prenatal diagnosis of interrupted inferior vena cava as an isolated finding: a benign vascular malformation.

We report two cases of interrupted inferior vena cava with azygous continuation diagnosed as an isolated finding during routine prenatal scans. Visualization of the venous vasculature of the abdomen and thorax in the mid-sagittal plane failed to visualize the segment of the inferior vena cava between the kidneys and the liver. A vessel with venous flow was observed parallel, adjacent and posterior to the aorta between the kidney and the right atrium. This blood vessel connected with the superior vena cava. Axial planes of the thorax confirmed the presence of two vessels running paravertebrally. A detailed ultrasound examination of the fetal anatomy failed to demonstrate other anomalies. The neonatal course of both fetuses was uneventful. Isolated interruption of the inferior uena cava can be a vascular malformation without known pathological consequences.

Low-level exercise echocardiography detects contractile reserve and predicts reversible dysfunction after acute myocardial infarction: comparison with low-dose dobutamine echocardiography.

OBJECTIVES: The aim of this study was to evaluate low-level exercise echocardiography (LLEE) in detecting contractile reserve and predicting functional improvement of akinetic myocardium early after acute myocardial infarction (AMI). BACKGROUND: Experimental and clinical studies have shown that low-dose dobutamine enhances contractile function of dyssynergic but viable myocardium in patients with recent AMI. We hypothesized that endogenous catecholamines produced during a LLEE test could serve as a myocardial stressor to elicit contractile reserve. METHODS: Fifty-two consecutive patients with first AMI and > or =2 akinetic segments in the infarct-related territory underwent 5 +/- 2 days after AMI low-dose dobutamine echocardiography (LDDE) (5, 10 and 15 microg/kg/min) and LLEE (25 W during 3 min on a supine bicycle, with continuous echocardiographic recording). Both tests were performed on the same day, in random order. Follow-up echocardiography was obtained one month later. Regional wall thickening was semi-quantitatively assessed using a 16-segment, 5-grade scale model. Contractile reserve was defined as improvement in wall thickening of > or =1 grade. RESULTS: Mean increase in heart rate during stress tests was 15 +/- 7 beats/min with LLEE and 13 +/- 6 beats/min with LDDE (p = NS). Contractile reserve was detected in 119 (55%) of 217 akinetic segments at LLEE and in 137 (63%) segments at LDDE. At follow-up study, functional improvement was identified in 139 (64%) segments. Sensitivity, specificity and positive and negative predictive values for predicting functional recovery were 81%, 92%, 95% and 73%, respectively, for LLEE, and 91%, 86%, 92% and 84%, respectively, for LDDE. Moreover, there was a good correlation between systolic wall thickening measured in the center of the dyssynergic area during stress tests and at follow-up study: r = 0.77, p < 0.001 with exercise testing and r = 0.73, p < 0.001 with dobutamine testing. CONCLUSIONS: Low-level exercise echocardiography provides a promising alternative to LDDE for identifying myocardial viability and predicting reversible dysfunction early after AMI.

The effect of betamethasone on fetal biophysical activities and Doppler velocimetry of umbilical and middle cerebral arteries.

OBJECTIVE: Preliminary reports suggest that antenatal steroid administration may confound the assessment of fetal well-being by suppressing biophysical activities, consequently drug-induced effects could prompt unwarranted delivery of premature fetuses. The purpose of this study was to examine the effect of antenatal betamethasone administration on fetal biophysical activities and Doppler flow indices of the umbilical and middle cerebral circulation. METHODS: Forty women at risk of premature delivery between 27-32 weeks gestation (mean 30.2 weeks) received two consecutive doses of intramuscular betamethasone, 24 hours apart. Ultrasonographic observations of fetal behavior for 30 minute periods and Doppler examination of the umbilical and cerebral arteries were performed prior to (0 hours), 48 hours after, and 96 hours after administration of the first dose. To account for fetal circadian rhythms and maternal prandial status, all examinations were carefully timed and performed between 1-4 pm. Analysis of Variance, chi-square test and Fisher's Exact test were used for statistical analysis, as appropriate. RESULTS: Nine patients were excluded from analysis due to delivery prior to completion of all examinations. Number of breathing episodes as well as total breathing time at 48 hours decreased by 83.0% (p<0.01) and 90.4% (p<0.01), respectively, at 48 hours in comparison to baseline. Fetal limb and trunk movements decreased by 53.2% (p<0.01) and 48.6% (p<0.01), respectively. Amniotic fluid volume and fetal tone were normal in all patients. At 48 hours, 14 of 31 fetuses and 4 of 31 fetuses had a biophysical profile score of 6/8 and 4/8, respectively, in comparison to 0 of 31 and 0 of 31 at 0 hours (p<0.05 and p<0.001, respectively). All parameters returned to baseline values at 96 h. Pulsatility indices of umbilical and middle cerebral arteries remained unchanged at 48 hours and 96 hours (p=NS). CONCLUSIONS: Betamethasone induces a profound, albeit transient, suppression of fetal breathing, limb and trunk movements, resulting in decreased biophysical profile scores. Awareness of this drug-induced effect might prevent unnecessary iatrogenic delivery of preterm fetuses.

Maternal infectious morbidity following multiple courses of betamethasone.

OBJECTIVE: the beneficial effects of antepartum corticosteroids on the reduction of morbidity and mortality in the premature neonate have been amply demonstrated. The NIH consensus statement has, therefore, endorsed their use in women at risk from pre-term delivery between 24 and 34 weeks gestation. Patients at persistent risk of pre-term delivery nay receive multiple weekly courses. However, increased susceptibility to infection is a well-recognized complication of prolonged high-dose steroid therapy. We examined infectious morbidity among women exposed to three or more courses of betamethasone. METHODS AND OUTCOMES MEASURES: thirty-seven patients at risk of pre-term delivery who received three or more courses of betamethasone (median = 6: range 3-10) and 74 normal controls, matched for maternal age, route of delivery, and year of delivery were included in the study. Data on medical care provided to study and control patients between 24 weeks gestation and 6 weeks postpartum were retrieved from centralized medical records. Incidences and types of infections were compared by Chi-square and Fisher's exact test, as appropriate. Only infections diagnosed at least 1 week after betamethasone therapy was initiated were included. Patients with pre-existing conditions predisposing to infectious morbidity were excluded. RESULTS: twenty-four of 37 patients (64.8%) exposed to betamethasone vs. 13 of 74 (17.5%) controls developed infectious diseases (P < 0.001). Symptomatic lower urinary tract infections occurred in 13 of 37 (35.1%) and two of 74 (2.7%) in the study and control groups, respectively (P < 0.001). Serious bacterial infections were found in nine of 37 (24.3%) vs. none of 74 (0%) patients, respectively (P < 0.001). These included sepsis (n=2), pneumonia (n=4), pyelonephritis (n=2), and cholangitis (n=1). Eight of nine serious infections occurred in patients exposed to five or more weekly courses of betamethasone. Postpartum endometritis related to Caesarean delivery was found in five of 37 patients (13.5%) vs. seven of 74 (9.4%), respectively (P=NS). CONCLUSIONS: Three or more courses of antepartum betamethasone in women at risk of pre-term delivery are associated with substantial infectious maternal morbidity. The excess morbidity consisted mainly of bacterial infections, some of which were associated with systemic and potentially life-threatening infections.

Screening efficacy of the subcutaneous tissue width/femur length ratio for fetal macrosomia in the non-diabetic pregnancy.

BACKGROUND: Antenatal weight estimations have limited sensitivity and specificity for the detection of macrosomia. The objective of our study was to examine the screening efficacy of the subcutaneous tissue width/femur length ratio for the intrapartum detection of fetal macrosomia in a non-diabetic population at term. STUDY DESIGN: Intrapartum sonographic measurements were performed in 178 well-dated gravidas at 37-41 weeks' gestation with negative glucose tolerance screens. The biparietal diameter, femur length (FL), abdominal circumference and subcutaneous tissue width of the thigh (SCT) were determined. Subsequently, predictions for macrosomia (actual birth weights above the 90th centile) were made using varying cut-off points of the examined parameters or estimated fetal weights. RESULTS: Macrosomia occurred in 27 newborns (15.1%). The SCT/FL ratio was independent of gestational age (r = -0.017). Maternal age, gravidity, parity, gestational age and the ratio of male-to-female infants were similar in pregnancies resulting in appropriate-for-gestational-age and macrosomic infants (NS). There was no difference in the SCT/FL ratio between these groups (p = 0.067; 99% power to detect 2 standard deviation differences). Comparison of screening efficacy by the univariate z score for the area under receiver operating characteristic (ROC) curves (theta) revealed that the abdominal circumference had the best sensitivity-specificity trade-off (theta = 0.8843; p < 0.0001 for comparison with SCT/FL ROC curve), followed by weight estimations based on the Hadlock formula (theta = 0.8773; p < 0.0005), the Shepard formula (theta = 0.8606; p < 0.0001), subcutaneous tissue thickness alone (theta = 0.6872; p < 0.01) and the SCT/FL ratio (theta = 0.6303). CONCLUSIONS: We conclude that the SCT/FL ratio is a poor sonographic predictor of fetal macrosomia in the non-diabetic pregnancy and does not improve fetal weight estimations by conventional sonographic parameters.

The effect of betamethasone and dexamethasone on fetal heart rate patterns and biophysical activities. A prospective randomized trial.

UNLABELLED: BACKGROUND; Contradictory findings on the effect of betamethasone versus dexamethasone on antenatal tests of fetal well-being have been reported. The purpose of this study was to compare the effects of these steroid compounds on fetal heart rate patterns and biophysical activities in a prospective. randomized trial. STUDY DESIGN: Forty-six pregnant women (gestational age range 27-34 weeks) at risk for preterm delivery were randomized to receive betamethasone or dexamethasone for enhancement of fetal lung maturity. Fetal heart rate was recorded for 60 minutes and analyzed with the Sonicaid System 8000 before (0 hours), and 48 hours and 96 hours after steroid administration. Subsequently, fetal limb, body and breathing movements were sonographically observed and quantified for 30 minutes. To account for fetal circadian rhythms, all examinations were performed between 1 p.m. and 5 p.m., at least one hour after maternal meals. RESULTS: Fetal heart rate accelerations (p<0.001; p<0.01), short-term variation (p<0.0001; p<0.05), long-term variation (p<0.01; p=NS), duration of high episodes (p<0.001; p<0.05), total movement count (p<0.001; p<0.05), and duration of breathing time (p<0.0001; p<0.0001) were substantially reduced 48 h after betamethasone and dexamethasone administration, respectively, with percent reduction being larger for the betamethasone group, except for breathing movements (p<0.05; p<0.001; p<0.001; p<0.005; p<0.05; p=NS; respectively). In 68.2%( and 45.5% of fetuses, less than 30 seconds of continuous breathing movements were found in the betamethasone and dexamethasone groups, respectively. In 71.8% and 12.5%, of fetuses, respectively, less than 2 body/limb movements were observed. Therefore five and two fetuses in the betamethasone and dexamethasone study group, respectively, had both nonreactive fetal heart rate monitors for 60 minutes and biophysical profiles of < or =4/10. All parameters returned to baseline values at 96 h. Baseline fetal heart rate and numbers of decelerations remained unchanged (p=NS). CONCLUSIONS: Both betamethasone and dexamethasone induce a profound, albeit transient, suppression of fetal heart rate characteristics and biophysical activities in the preterm fetus. However, the effect of betamethasone is more pronounced. Awareness of these phenomena might prevent unwarranted iatrogenic delivery of preterm fetuses.

Midtrimester maternal serum screening after multifetal pregnancy reduction in pregnancies conceived by in vitro fertilization.

PURPOSE: Data about the effect of multifetal pregnancy reduction on midtrimester maternal serum levels of alpha-fetoprotein (AFP), human chorionic gonadotropin (hCG), and unconjugated estriol (uE3) are scarce and contradictory. Differing gestational ages at fetal reduction, transvaginal versus transabdominal needle insertion, and injection of different feticidal agents compound the analysis of published data. METHODS: We examined clinical and laboratory data about 27 high-order gestations that were reduced to twins in the first trimester. Fetal reductions were performed transabdominally at 11.41 +/- 1.15 weeks' gestation by fetal intrathoracic injection of KCl, and maternal blood sampling was performed at 16.48 +/- 1.05 weeks. "Pseudo-risks" for singleton pregnancies were calculated by correcting serum analyte levels for twins. RESULTS: Twenty-four (88.9%) of 27 patients had maternal serum AFP levels above 2.0 MoM (mean, 4.60 +/- 3.48 MoM; range, 1.49-14.85 MoM), however, none of the newborns had structural anomalies. AFP serum levels did not correlate with the number of reduced fetuses or with adverse obstetric outcome. The mean hCG levels were 1.22 +/- 0.49 MoM (range, 0.14-2.47), and the mean uE3 levels were 1.15 +/- 0.31 MoM (range, 0.56-1.84). Based on maternal age alone, seven patients (25.9%) would have been offered amniocentesis for a term Down syndrome risk greater than 1:384, whereas combined risk calculations with hCG and uE3 levels resulted in 1 (3.7%) screen-positive case (P < 0.01).

Uterine artery Doppler velocimetry in pregnant women with lateral placentas.

The aim of this study was to compare the efficacy of placental, non-placental, mean of both uterine arteries Doppler velocimetry at 22-24 weeks gestation in the prediction of pregnancy induced hypertension (PIH) and intrauterine growth retardation (IUGR). Flow velocity waveforms were obtained by means of color and pulsed Doppler in 481 patients with lateral placentas at 22-24 weeks gestation. Placental location was determined by real time ultrasonography. Comparisons were performed between controls and pregnancies complicated by PIH and IUGR. Sensitivities, false positive rates and positive predictive values for PIH and IUGR of resistance indices (RI) above the 90th percentile, and diastolic notches in placental, non-placental or both uterine arteries were calculated. A mean uterine artery RI > or = 0.66 (90th centile) had better sensitivity than the placental (26.8% vs 17.1% for IUGR and 41.7% vs 33.3% for PIH) and the non-placental uterine artery (26.8% vs 21.9% for IUGR and 41.7% vs 33.3% for PIH). The presence of a diastolic notch in the placental uterine artery increased sensitivity (31.7% for IUGR and 50.0% for PIH) and positive predictive value of the test. In patients with laterally implanted placentas a mean of both uterine arteries RI above the 90th centile and the presence of a diastolic notch in the placental uterine artery at 22-24 weeks have a higher predictive value for the subsequent development of PIH and IUGR than the separate evaluation of the 2 uterine arteries.

Cardiotocographic and Doppler velocimetric patterns, pre- and post-thoracentesis, in a case of fetal hydrothorax.

Fetal hydrothorax is associated with elevated perinatal mortality. Management of this condition is controversial given that in utero spontaneous resolution has been described. A case of fetal hydrothorax associated with an extralobar lung sequestration that showed pathologic cardiotocographic patterns and abnormal Doppler velocimetry indices in several fetal vascular beds in reported. All pathologic patterns improved after fetal thoracentesis. It can be concluded that monitoring fetal well-being by means of cardiotocography and Doppler velocimetry may help in timing thoracentesis in cases of fetal hydrothorax.

Doppler velocimetry of the uterine and fetal circulations during prostaglandin E2 cervical ripening.

The objective of the study was to investigate flow characteristics of the maternal uterine and fetal umbilical and middle cerebral arteries following intracervical administration of prostaglandin E2 (PGE2). Doppler velocimetry of uterine, umbilical and middle cerebral arteries was performed immediately before and 2 h after PGE2 administration in 28 women with uncomplicated post-term pregnancy and an unfavorable cervix. Placental position was determined in all cases. When all patients were considered jointly, regardless of placental position, the mean uterine artery resistance index (RI) values were 0.41 +/- 0.07 before and 0.48 +/- 0.13 2 h after PGE2 administration (p < 0.05). When patients with lateral placentas (n = 20) were analyzed separately, only the non-placental uterine artery showed a significant increase 2 h after PGE2 administration, whereas no significant differences were found in the placental uterine artery. No changes were observed in uterine RI values of patients with central placentas. No significant differences were observed for umbilical artery and middle cerebral artery before and after PGE2 administration. It is concluded that intracervical PGE2 administration increases uteroplacental resistance but probably does not substantially affect placental perfusion; that the umbilical circulation is not affected; and that there were no signs of redistribution of fetal blood flow.

Immunoperoxidase demonstration of Chlamydia inclusions in routine Pap-smears.

Indirect immunoperoxidase with antichlamydia serum has been applied to 34 Pap-smears where cytologic diagnosis of Chlamydia infection was suspected. Only 4 cases were confirmed by this technique. The limited success could be due to the need for a more active antiserum or to an overestimation of Pap-smear images. Cytologic diagnostic features are critically outlined.