Arterial and venous Doppler velocimetry in the severely growth-restricted fetus and associations with adverse perinatal outcome.

OBJECTIVE: To evaluate the association between arterial and venous Doppler waveforms and adverse perinatal outcome in severe intrauterine growth restriction. DESIGN: Fetuses between 26 and 32 weeks' gestation with ultrasonographically estimated fetal weight below the 5th centile were included in this prospective study. The last Doppler measurements of the umbilical artery, ductus venosus, umbilical vein and middle cerebral artery before delivery and adverse outcome parameters without gestational age independence were used for statistical analysis. Adverse outcome parameters were defined as the following: fetal demise or neonatal death in the first 30 days of life; 5-min Apgar score of < 7; intubation at birth; retinopathy of prematurity; respiratory distress syndrome; necrotizing enterocolitis; stay in neonatal intensive care unit of more than 60 days; intraventricular hemorrhage; periventricular leukomalacia. RESULTS: Nineteen fetuses fulfilled the inclusion criteria. Perinatal death, low 5-min Apgar values and necrotizing enterocolitis were gestational age-independent adverse outcome parameters. Abnormal Doppler velocimetry of the ductus venosus was the only significant parameter associated with perinatal death and low 5-min Apgar scores. None of the Doppler parameters predicted necrotizing enterocolitis. CONCLUSION: Our data suggest that management of severely growth-restricted fetuses may be aided by the study of ductus venosus Doppler velocimetry.

The effect of intravascular blood transfusion on the flow velocity waveform of the portal venous system of the anemic fetus.

Our objective was to assess flow velocity waveforms of the portal venous system of the anemic fetus prior to and immediately following intravascular transfusion. Color-guided pulsed Doppler was used to obtain flow velocity waveforms from the fetal portal vein in 14 anemic fetuses that were transfused in utero for rhesus alloimmunization The portal vein velocity pattern was defined as continuous when no change in velocity during the cardiac cycle was noted. It was defined as pulsatile when a deflection of the wave was present. The flow velocity waveforms were quantified by using the ratio between the peak (highest, H) and the nadir (lowest, L) velocities (H/L ratio). Fourteen intravascular transfusions were performed. Gestational age ranged from 19.5 to 35 weeks (mean +/- SD, 26.7 +/- 5.3 weeks). The hematocrit ranged from 5.9 to 31.2% (mean +/- SD, 20.3 +/- 9%) prior to transfusion; after transfusion it was between 24.8 and 56.7% (mean +/- SD, 42 +/- 10.4%). In six cases (43%) the waveforms were pulsatile prior to transfusion; in the other eight (57%) they were continuous. The pulsatile pattern was present following transfusion in 13 cases (93%, p < 0.05). The mean of the H/L ratio was 1.3 +/- 0.38 prior to transfusion and 2.0 +/- 0.86 after transfusion (p < 0.05). Because the portal vein has continuous non-pulsatile flow in the normal fetus, the presence of pulsatility in the waves of six anemic fetuses (43%) may suggest portal hypertension. Compared to normal fetuses, there was an increased number of cases with pulsation, and even more so after transfusion. The pattern corresponds to findings in children with portal hypertension.

Ultrasonographically adjusted midtrimester risk of trisomy 21 and significant chromosomal defects in advanced maternal age.

OBJECTIVE: Our purpose was to determine whether normal midtrimester ultrasonography results reduces the risk of fetal Down syndrome and any clinically significant chromosomal defects in pregnancies with advanced maternal age and to develop risk tables on the basis of age and ultrasonographic results. STUDY DESIGN: Biometry data were obtained in 4079 women between 15 and 24 weeks undergoing amniocentesis for maternal age. Expected values of humerus, femur, both combined, and abdominal circumference based on biparietal diameter were generated from a normal group. Observed/expected values of each parameter and nuchal thickness > or = 6 mm was used to screen for Down syndrome and any clinically significant chromosome defects. Receiver-operator characteristic curves were used to determine threshold screening values for each parameter. By use of stepwise logistic regression the optimal measurements for detection of chromosome anomalies were established. An abnormal ultrasonography result was defined as either abnormal biometry choroid plexus cysts or a structural defect. RESULTS: The finding of shortened humerus (observed/expected < 0.90), abnormal nuchal thickness, or an anatomic defect had the highest sensitivity for Down syndrome detection, 70.6%, p < 0.0001, whereas a short humerus, small abdominal circumference, (observed/expected < 0.92), or an anatomic defect had a sensitivity of 46.7%, p < 0.0001, for any significant chromosome defect. With a normal ultrasonography the risk of Down syndrome in a 39-year-old woman falls from 1:100 to < 1:292. CONCLUSION: A normal ultrasonography substantially reduces the risk of Down syndrome and any chromosome abnormality. This information is useful in counseling women who decline amniocentesis on the basis of maternal age.

[Hematocrit and hemoglobin, parameters of hematic viscosity, in pregnancy-induced hypertension]. / L'ematocrito e l'emoglobina, parametri di viscosità ematica, in corso di ipertensione gravidanza-indotta.

During pregnancy because of physiologic hemodiluition and changes in various plasma protein levels, plasma viscosity is decreased compared to the non pregnant condition. Specifically the whole blood viscosity profile throughout pregnancy follows that of the hematocrit. However some pathological condition like pregnancy induced hypertension and intrauterine growth retardation are characterized by an increase of plasma viscosity. In order to evaluate the effect of plasma viscosity on placental perfusion, in 41 patients affected by pregnancy induced hypertension and with no iron deficiency we compared maternal hemoglobin and hematocrit to the birth weight. High maternal hemoglobin and hematocrit levels were associated to an increased frequency of low weight for date newborns (less than or equal to 10th centile), although the relationship with the hemoglobin levels is stronger (p less than or equal to 0.02) than the one with the hematocrit (p less than or equal to 0.05). In contrast, high weight for date newborns (greater than or equal to 90th centile) were not related to maternal hemoglobin and hematocrit parameters. We found that maternal hemoglobin and hematocrit, indicators of plasma viscosity, are useful in predicting low birth weight, but not high birth weight. We speculate that hypoxia due to the modification of microcirculation is a very important factor in determining the low birth weight; in contrast the oxygen is not the only factor involved in determining the high birth weight.

Use of GnRH depot analogue in the treatment of uterine fibroids.

Twelve patients with symptomatic uterine fibroid were treated with Goserelin acetate, a depot Gn-RH analogue administered s.c. in a dosage of 3.6 mg every 28 days for a 6 month period. Mean age of the patients was 39 (26-47). A menopausal-like state, evidenced by hot flushes, depression, vaginal dryness, hysteroscopic endometrial atrophy, and hormonal values (FSH, LH, E2), was seen in all patients. After only two months of treatment, a significant reduction was noted in the size of the fibroid, being even greater than that in the following four months. Only one patient in the series underwent surgery. General tolerability of the drug was optimal. These data suggest the efficiency of this type of treatment in obtaining a significant reduction of fibroid volume as well as subjective symptomatology. The cost-benefit ratio is optimal, allowing postponement of surgery and the possibility of vaginal, as opposed to abdominal, hysterectomy and affronting problems of anaesthesiology and post-operative recovery for patients "at risk".