First Trimester Cystic Hygroma: Herald to Early Diagnosis of Congenital Diaphragmatic Hernia.

The early diagnosis of in utero congenital diaphragmatic hernia (CDH) allows a thorough evaluation for other morbidities that may be associated with CDH. Our patient was referred to us with a fetus at 13 weeks gestational age with a thick nuchal translucency. Our team performed a transvaginal ultrasound that revealed a large ystic hygroma, a heart displaced to the right, and a heterogeneous mass with peristalsis in the left chest. The fetus was diagnosed with CDH. The patient received genetic counseling after which she requested and underwent chorionic villus sampling. The early diagnosis of CDH allows for a timely intervention with the improved management of pre-natal and post-natal care. Better neonatal management is pivotal in providing a multidisciplinary consultation approach in order to furnish accurate counseling and prognostic information for the patient.

Fetal surface placental hematomas: the clue in the diagnosis of a bleeding dyscrasia.

Von Willebrand disease (vWD) is the most common inherited bleeding disorder in humans, occurring in about 1% of women and caused by a deficiency or abnormality in the von Willebrand factor (vWF). There are different types of vWD. Type I comprises approximately 80% of the cases, its inheritance is autosomal dominant. Women with vWD have a 10-fold risk of having antepartum bleeding when compared to the general population. We report a case of von Willebrand disease diagnosed due to findings on a routine ultrasound evaluation.

Prenatal ultrasonographic detection of ophthalmic diseases.

Four patients with prenatal sonographic findings suggestive of ophthalmic pathology were detected in utero. The definitive diagnoses of infantile fibrosarcoma, persistent hyperplastic primary vitreous/persistent fetal vasculature, Fraser syndrome, and microphthalmia with coloboma and retrobulbar cyst were made postnatally. High-resolution intrauterine sonograms expedited ophthalmic referral and influenced prenatal planning.

Outcome of pregnancies among Hispanics: revisiting the epidemiologic paradox.

OBJECTIVE: To evaluate the outcome of pregnancies among Hispanics in a tertiary care hospital in Miami, Florida. STUDY DESIGN: Retrospective study of all women who delivered in our institution over an 11-year period. Outcome variables were stratified by race/ethnicity groups: Hispanics, non-Hispanic blacks and non-Hispanic whites. Variables included rates of low birth weight (LBW), preterm delivery (PTD) and other selected pregnancy outcomes. RESULTS: Thirty-five percent were of Hispanic origin, mainly of Caribbean, Central American and South American origin. Hispanics had the lowest rate of LBW (9%) when compared to blacks, non-Hispanics (18%) and white non-Hispanics (11%) (p < 0.0001). Hispanic women were less likely to deliver prematurely, at < 37 weeks (adjusted odds ratio [AOR] 0.68, 95% CI 0.65-0.91, p < 0.0001), < 32 weeks (AOR 0.57, 95% CI 0.52-0.63, p < 0.0001) and < 28 weeks (AOR 0.66, 95% CI 0.51-0.65, p < 0.0001). Hispanic women were less likely to have preterm premature rupture of membranes (AOR 0.66, 95% CI 0.58-0.75, p < 0.0001). CONCLUSION: Hispanics have the lowest PTD and LBW rates when compared to non-Hispanic whites and blacks.

Fetal growth rates and the very preterm delivery of twins.

OBJECTIVE: Our objective was to determine whether slow fetal growth rates and twin growth patterns from 20 weeks' gestation to delivery are associated with very preterm delivery. STUDY DESIGN: Available charts were reviewed for twin pregnancies, delivered between 1979 and 2002, at 4 U.S. medical centers. The sample of 1612 pregnancies delivered at 28 week's gestation or greater and had at least 2 ultrasound evaluations of fetal size from 20 to 28 weeks or from 28 weeks to delivery for estimation of fetal growth rates (grams per week). Slow fetal growth (below the 10th percentile) was defined as less than 90 grams per week at 20-28 weeks and 168 g/week from 28 weeks to delivery. The main outcome measure was the timing of delivery. RESULTS: Of the women delivering twins, 5.3% delivered extremely preterm (28-30 weeks), 8.5% very preterm (31-32 weeks), and 40.1% preterm (33-36 weeks). Patterns of growth for the pair were highly associated with very preterm delivery. Compared with neither growing slowly (1.7%), 4.9% delivered very preterm if only 1 twin grew slowly. Very preterm was 14.6% (adjusted odds ratio 9.81; 95% confidence interval, 3.50-27.48) with both growing slowly from 28 weeks on and 20.0% (adjusted odds ratio 15.04; 95% confidence interval 5.13-44.11) with both growing slowly over both intervals. Survival analyses indicated that twins with normal growth in both intervals remained undelivered for a significantly longer number of days (P < .0001) than pairs in which one or both twins were growing slowly. CONCLUSION: Very preterm delivery of twins seems to be preceded by slowed or compromised fetal growth for the pair.

The cost of twin pregnancy: maternal and neonatal factors.

OBJECTIVE: The purpose of this study was to evaluate factors affecting birth charges in twin pregnancies. STUDY DESIGN: Clinical and financial data were obtained on 1486 twin pregnancies delivered between 1995 to 2002 at medical centers in Maryland, Florida, Michigan, and South Carolina. Maternal and neonatal length of stay (LOS) and charges were modeled by gestational age and other risk factors using a general linear model. RESULTS: Maternal and infant birth admission LOS and charges increased significantly with a decline in gestational age. Maternal LOS and charges were also significantly increased by cesarean delivery and preeclampsia. Newborn LOS and charges increased significantly by monochorionicity and slowed growth between 20 to 28 weeks. For mother and infants, the shortest LOS and lowest birth charges were at 37 to 38 weeks. CONCLUSION: These findings reflect the substantial maternal and neonatal morbidity associated with twin pregnancies, and demonstrate that 37 to 38 weeks is their optimal gestation.

Genetic amniocentesis complications: is the incidence overrated?

AIMS: To estimate the complication rate of 2nd-trimester amniocentesis and to determine the associated risk factors. METHODS: A retrospective chart review of genetic amniocenteses performed at a single tertiary care institution, from 1996 to 1998, was done. The variables studied included gestational age, indication for amniocentesis, number and site of needle punctures, and amniotic fluid color. Complications included fetal loss, rupture of membranes, and bleeding. RESULTS: Out of the 1,347 procedures analyzed, the most common indications were advanced maternal age (72.3%) and abnormal triple screen (20.3%). Transplacental genetic amniocenteses totaled 234 (17.4%). Clear fluid was observed in 98.2% of the patients. Twenty-two complications (1.6%) were observed: fetal loss (0.22%), bleeding (0.59%), and rupture of membranes (0.82%). An abnormal karyotype was detected in 34 (2.5%) fetuses. In separate univariate logistic regression analyses, complications were significantly associated with gestational age [odds ratio OR = 1.19; 95% confidence interval CI = (1.08, 1.32); p = 0.001], number of punctures [OR = 8.2; 95% CI = (1.76, 37.97); p = 0.007], and ultrasound anomalies [OR = 5.82; 95% CI = (1.65, 20.58); p = 0.006]. Gestational age and number of punctures remained significant in multivariate logistic regression analysis. CONCLUSIONS: Genetic amniocentesis performed at a tertiary care institution is rather safe, and the fetal loss rate of 0.22% is significantly lower (p < 0.001) than the previously published incidence of 1/200. The risk of complications is significantly and independently associated with advanced gestational age and number of punctures.

Outcomes of pregnancies with sonographically detected nuchal cords remote from delivery.

OBJECTIVE: To evaluate the outcomes of pregnancies with sonographically detected nuchal cords remote from delivery during the second and third trimesters of gestation. METHODS: A retrospective study of patients with and without nuchal cords detected by sonography during the second and third trimesters of gestation (17-36 weeks) was conducted. Variables included maternal age, parity, gestational age at sonography and at delivery, method of delivery, intrapartum fetal heart abnormalities, meconium-stained amniotic fluid, birth weight, 5-minute Apgar score, and neonatal intensive care unit admissions. RESULTS: A total of 233 patients were included in this study, of which 118 had sonographically detected nuchal cords identified in our department during the study period. There were no statistically significant differences between patients with sonographically detected nuchal cords and control patients with respect to maternal age, estimated gestational age at sonography, method of delivery, meconium-stained fluid, birth weight, intrapartum fetal heart abnormalities, 5-minute Apgar scores of less than 7, and neonatal intensive care unit admissions. Patients with nuchal cords detected by sonography were more likely to give birth before 37 weeks' gestation than control patients (21% versus 11%; P = .040). CONCLUSIONS: A sonographically detected nuchal cord is not associated with important perinatal complications.

The association between maternal factors and perinatal outcomes in triplet pregnancies.

OBJECTIVE: The purpose of this study was to evaluate the associations between maternal factors and outcomes in triplet pregnancies. STUDY DESIGN: This was a historic cohort study of 194 triplet pregnancies of >or=24 weeks of gestation that were delivered from 1983 through 2001 from five medical centers. RESULTS: In analyses that were limited to pregnancies with all live-born triplets (178 pregnancies), women with a previous good outcome (>2500 g + >37 weeks of gestation) had longer gestations (+7.9 days, P =.03), better rates of fetal growth (+4.9 g/wk, P <.0001), and higher birth weights (+153 g, P <.0001). Maternal weight gains of <36 pounds by 24 weeks of gestation were associated with lower birth weights (-197 g, P <.0001), and fetal growth rates at

The effects of amnioinfused solutions for meconium-stained amniotic fluid on neonatal plasma electrolyte concentrations and pH.

OBJECTIVE: To determine if amnioinfused normal saline or lactated Ringer's solution in cases of meconium-stained amniotic fluid is associated with significant changes on neonatal plasma electrolyte concentrations or pH. STUDY DESIGN: This was a prospective randomized study using normal saline or lactated Ringer's solution for amnioinfusion in women with thick meconium in the amniotic fluid. The control group was composed of women with clear amniotic fluid not receiving amnioinfusion. Cord blood arterial sampling was analyzed for sodium, potassium, and chloride plasma concentrations and pH. The sample sizes allowed for an alpha of 0.05 and power of 0.80. RESULTS: We evaluated 61 cases (20 normal saline solution, 20 lactated Ringer's solution, and 21 control). No significant differences in cord blood arterial plasma concentrations of sodium (p=0.43), potassium (p=0.21), chloride (p=0.68), and pH (p=0.11) were noted. CONCLUSION: Use of normal saline or lactated Ringer's solution for amnioinfusion in meconium-stained amniotic fluid is not associated with changes on neonatal plasma electrolyte concentrations or pH.

Comparison of the endocervical brush and the endocervical curettage for the evaluation of the endocervical canal

OBJECTIVE: To evaluate and compare the efficacy in obtaining an adequate endocervical sampling using the endocervical brush and the endocervical curettage. METHODS: Analysis of the cytology and histology of samples obtained from patients referred to the University of Puerto Rico School of Medicine Tertiary Care Center Anaplasia Clinics for colposcopy due to an abnormal Pap smear having atypical cells or higher as classified according to the Bethesda System. All patients underwent evaluation of the endocervical canal with an endocervical brush and an endocervical curettage. RESULTS: Fifty three of fifty-eight patients had correlating endocervical brush Papanicolaou smear and endocervical curettage. Only five patients presented discrepancies. All endocervical brush samples had sufficient tissue for diagnosis. CONCLUSION: The endocervical curettage is operator dependent, is difficult to perform in patients with a stenotic cervical os or in menopausal patients. The endocervical brush is easier to use, malleable and has a lower processing cost. In view of these findings evaluation of the endocervix can be safely performed with the use of an endocervical brush. When used properly, the endocervical brush has a sensitivity of 90 per cent , a specificity of 92.1 per cent and a positive predictive value of 87.5 per cent