Fetal MRI: is it really helpful?

OBJECTIVE: The aim of this study is to emphasize on the diagnostic effectiveness of fetal MRI that led to increased utilization in fetal medicine as well as its value in prognosis and decision making in the modern obstetric practice. METHODS: One hundred five (n = 105) pregnant women were referred for a fetal MRI examination after a high detailed ultrasound examination revealed a fetal abnormality. Fetal MRI was performed using 1, 5 Tesla units, with T1, T2-weighted and diffusion-weighted images. The findings were analyzed in comparison to the previous ultrasound findings, according to the fetal organ affected and the value of the MRI for therapeutic decision making was addressed. A statistical analysis was performed. RESULTS: The fetal MRI provides a more accurate diagnosis compared to ultrasound examination, and when the ultrasound detects fetal anomalies, the MRI can efficiently either confirm or reject the finding, proving its high value for prenatal diagnosis and perinatal and management. The sensitivity, specificity and positive predictive value of fetal MRI as a screening tool approaches 100%. CONCLUSIONS: Despite the fact that ultrasound is the method of choice for fetal screening, MRI can add up significantly to the diagnosis and management of congenital abnormalities and the indications for MRI continue to increase as new sequences and shorter acquisition times evolve.

Three-dimensional power Doppler ultrasound for the study of cervical cancer and precancerous lesions.

OBJECTIVE: To evaluate the blood flow characteristics of the cervix in normal women and in women with cervical precancerous lesions or cervical cancer. METHODS: We studied 165 women with three-dimensional power Doppler ultrasound (3D-PDU), of whom 71 had cervical cancer, 61 had precancerous lesions and 33 were healthy controls. The cervix was manually traced in the stored volumes using 15° rotation steps and the following 3D-PDU indices were calculated: vascularization index (VI), flow index (FI) and vascularization flow index (VFI). These indices were compared among the study groups and were also correlated with features of the precancerous lesions group and cancer group. RESULTS: The three indices were all statistically significantly higher in the cervical cancer group and precancerous lesions group than in controls (P < 0.001). In addition, significantly higher values of all indices were found in the cervical cancer group than in the precancerous lesions group (P < 0.001). Further analysis according to patient characteristics in the cancer group showed that VI, FI and VFI were not significantly different in relation to grade, histology, presence of positive lymph nodes or lymphovascular space involvement (P > 0.05). However, VI was significantly higher in patients with Stages IIIB-IV cancer than in patients with less advanced disease (P = 0.045). In the cervical cancer group there was a significant positive correlation between 3D-PDU indices and cervical volume. CONCLUSION: 3D-PDU assessment of the cervix reveals significant differences in all indices studied between women with cervical precancerous lesions or cancer and healthy women. In women with cervical cancer, an advanced stage is associated with higher VI, but 3D-PDU indices are not related to other pathological characteristics.

Regeneration of uterine cervix at 6 months after large loop excision of the transformation zone for cervical intraepithelial neoplasia.

OBJECTIVE: To sonographically investigate cervical regeneration 6 months after large loop excision of the transformation zone (LLETZ) conisation for cervical intraepithelial neoplasia (CIN) pathology. DESIGN: Prospective observational study. SETTING: University Hospital setting. POPULATION: Women having LLETZ conisation for intraepithelial lesions in response to abnormal Papanicolaou smears or colposcopic findings. METHODS: Cervical dimensions were estimated before conisation and at 6 months with three-dimensional sonography and use of vocal™ software. Cone depth was measured using a ruler before fixation, and cone volume was measured using a volumetric tube and the fluid displacement technique. Cervical regeneration was sonographically estimated. MAIN OUTCOME MEASURES: Correlation of cervical volume regeneration with percentage of initial cervical volume excised and remaining cervical tissue immediately after conisation. RESULTS: A cohort of 112 women were initially recruited over a 2-year period and 73 women presented for ultrasound follow up at 6 months. Multivariate linear regression analysis showed that for women matched for age and initial cervical volume, if cervical volume excised was increased by 1% then regeneration of tissue deficit at the cervical crater was reduced by 1.37%. There also seemed to be a cutoff point suggesting that when >14% of initial cervical volume was excised, the tissue deficit at the cervical crater at 6 months was restored by <75% and there was >25% of remaining tissue deficit. CONCLUSIONS: Cervical regeneration at 6 months after excision is dependent on the percentage of initial cervical volume excised and on the remaining cervical tissue immediately after conisation. The greater the cone and the less cervical tissue remaining, the less the degree of cervical regeneration achieved.

The contribution of three-dimensional power Doppler imaging in the preoperative assessment of breast tumors: a preliminary report.

Purpose. The aim of this study was to determine the value of 3D and 3D Power Doppler sonography in the detection of tumor malignancy in breast lesions and to find new diagnostic criteria for differential diagnosis. Methods. One hundred and twenty five women with clinically or mammographically suspicious findings were referred for 3D Power Doppler ultrasound prior to surgery. Histological diagnosis was conducted after surgery and compared with ultrasound findings. Sonographic criteria used for breast cancer diagnosis were based on a system that included morphological characteristics and criteria of the vascular pattern of a breast mass by Power Doppler imaging. Results. Seventy-two lesions were histopathologically diagnosed as benign and 53 tumors as malignant. Three-dimensional ultrasound identified 49 out of 53 histologically confirmed breast cancers resulting in a sensitivity of 92.4% and a specificity of 86.1% in diagnosing breast malignancy (PPV: 0.83, NPV:0.94). Conclusions. 3D ultrasonography is a valuable tool in identifying preoperatively the possibility of a tumor to be malignant.

Amniotic fluid interleukin-18 at mid-trimester genetic amniocentesis: relationship to intraamniotic microbial invasion and preterm delivery.

OBJECTIVE: To determine the value of amniotic fluid interleukin-18 (AF IL-18) in the diagnosis of microbial invasion of the amniotic cavity and prediction of preterm delivery (PTD). DESIGN: Analysis of the results of AF collected prospectively following genetic amniocentesis between February 2006 and September 2007. SETTING: A tertiary referral centre for fetal medicine. METHODS: Following amniocentesis, a sample of amniotic fluid was transferred to the laboratory for aerobic and anaerobic bacterial cultures, Ureaplasma urealyticum culture and IL-18 assays. All women who delivered preterm (<37 weeks of gestation) formed the study group. The control group consisted of the two subsequent women who also underwent amniocentesis during the same time period and delivered a normal neonate at term, matched for maternal age, parity and indication for amniocentesis. MAIN OUTCOME MEASURES: The relationship between AF IL-18 levels and the risk of both microbial invasion of the amniotic cavity and PTD. RESULTS: Forty-eight women who delivered preterm (<37 weeks) were matched with 96 controls. The preterm delivery group had significantly higher concentrations of IL-18 (median=609 pg/ml, interquartile range: 445.7-782.7) compared to controls (median=322.1 pg/ml, interquartile range: 277.7-414.4), (P<0.001). IL-18 level was also significantly higher (P<0.001) in cases with positive amniotic fluid cultures (median=697.7, interquartile range: 609.0-847.2) compared to those with negative ones (median=330.9 pg/ml, interquartile range: 235.2-440.8). CONCLUSIONS: Elevated mid-trimester concentrations of AF IL-18 can identify women at risk for intraamniotic infection and spontaneous PTD.

Imperforate hymen with hematocolpometra combined with elevated Ca125.

In the present case, ultrasound examination ruled out the presence of hematosalpinx or other gynecological tumors. This was of great importance to the surgical intervention, especially for avoiding laparotomy. Dilatation of the vagina and uterus, due to imperforate hymen with retrograde menstruation should be considered in the differential diagnosis of abdominal pain in premenarchal girls (Fig. 2, Ref. 15). Full Text (Free, PDF) www.bmj.sk.

Uterine prolapse in pregnancy: a rare condition an obstetrician should be familiar with.

Uterine prolapse complicating pregnancy is a rare event. Early recognition is essential in order to avoid possible maternal and fetal risks. We report the case of a 37-year-old pregnant woman who presented to the antenatal outpatient clinic with uterine prolapse at 31(+1) weeks of gestation. Sonographic examination revealed an enlarged fibromatous uterus. She was conservatively treated on an inpatient basis. Two weeks later she underwent an emergency cesarean section because of preterm uterine contractions. A live male neonate weighing 1,900 g was delivered. We believe that conservative management with bed rest, followed by an elective cesarean section, may ensure an uncomplicated gestation and an uneventful delivery.

Henoch-Schonlein purpura in pregnancy.

Henoch-Schonlein purpura (HSP) is a hypersensitivity vasculitis. This is a case report of HSP during pregnancy and a review of the literature in this rare pregnant disease. We present a case of a 32-year-old woman with HSP. Treatment with low-dose oral corticosteroids was administered leading to a beneficial outcome for the fetus and the mother. Henoch-Schonlein purpura is the most common connective tissue disorder of children. It is rarely reported in adults. Only 16 cases of HSP during pregnancy have been described in the literature worldwide, and this is the 17th reported case.

Screening for pre-eclampsia by oxidative stress markers and uteroplacental blood flow.

Recent evidence suggests that the oxidative stress is an important factor in the pathophysiology of pre-eclampsia. The purpose of this study was to evaluate the possible relationship between increased resistance at the Doppler assessment of the uterine arteries between 20-23 gestational weeks and biochemical markers of oxidative stress, with the development of pre-eclampsia and/or growth restricted infants. This was a prospective study of 34 pregnant women with normal uteroplacental flow and 30 women with abnormal uterine arteries Doppler analysis (mean PI >or= 1.60) during the transvaginal assessment of the uterine arteries at the routine anomaly scan. Blood samples were obtained in order to assess the plasma oxidative stress, namely malondialdehyde (MDA) and uric acid levels. The MDA was significantly higher in the group of women with abnormal uterine arteries Dopplers. This group is at increased risk for the development of pre-eclampsia. The uric acid levels did not differ significantly between the two groups of women. There was no significant difference regarding the sensitivity or the specificity of the uterine arteries Doppler examination in detecting pre-eclampsia in comparison to the combination of oxidative stress and Doppler's. Our study provides additional evidence regarding the role of oxidative stress in the pathophysiology of pre-eclampsia. Whether antioxidant supplementation in the group of women with abnormal uterine Doppler's is effective in reducing the incidence of the disease remains to be established.

Cesarean vs. vaginal birth for term breech presentation in 2 different study periods.

OBJECTIVE: To compare outcomes for fetuses at term in breech presentation during 2 periods when different delivery policies were in effect. METHODS: Outcomes of the 392 planned vaginal deliveries and 1160 elective cesarean sections (CSs) performed from January 1, 1988, through December 31, 2000, were compared with those of the 24 emergency vaginal deliveries, the 403 planned CSs, and 75 emergency CSs performed from January 1, 2001 through December 31, 2004 at Alexandra Hospital, Athens, Greece. RESULTS: A significant difference was found in rates of low 5-minute Apgar score, birth trauma, serious neonatal morbidity, and admission to the neonatal intensive care unit (0% vs. 1.02% [P=0.004], 1.02% vs. 0% [P=0.004], 3.06% vs. 0.43% [P<0.001], and 2.8% vs. 0.43% [P<0.001], respectively) between neonates born by planned vaginal delivery and those born by elective CS during the first period. Only a reduction in rates of admission to the neonatal intermediate care unit was found between the first and second periods. CONCLUSIONS: Planned CS was found to be safer than planned vaginal delivery for fetuses at term in breech presentation. However, the study did not demonstrate that the change in policy improved neonatal outcome.

Screening for pre-eclampsia and fetal growth restriction by uterine artery Doppler and PAPP-A at 11-14 weeks' gestation.

OBJECTIVE: To assess the role of maternal demographic characteristics, uterine artery Doppler velocimetry, maternal serum pregnancy-associated plasma protein-A (PAPP-A) and their combination in screening for pre-eclampsia and small-for-gestational age (SGA) fetuses at 11-14 weeks. METHODS: This was a prospective study of 878 consecutive women presenting for a routine prenatal ultrasound examination at 11-14 weeks. Pulsed wave Doppler was then used to obtain uterine artery flow velocity waveforms and the mean pulsatility index (PI) of the uterine arteries was calculated. Maternal serum samples for PAPP-A were assayed. Along with maternal history, these measurements were compared in their ability to predict adverse outcome, defined as pre-eclampsia and/or SGA and/or placental abruption. RESULTS: Mean uterine artery PI > or = 95(th) centile and PAPP-A < or = 10(th) centile each predicted 23% of the women that developed pre-eclampsia and 43% of cases of placental abruption. For SGA < or = 5(th) centile, mean uterine artery PI > or = 95(th) centile predicted 23% of cases and PAPP-A < or = 10(th) centile predicted 34%. Independent predictors for subsequent development of pre-eclampsia were increased mean uterine artery PI > or = 95(th) centile (OR, 2.76; 95% CI, 1.11-6.81) and maternal history of pre-eclampsia/hypertension (OR, 50.54; 95% CI, 10.52-242.73). The predicting factors for SGA < or = 5(th) centile were increased mean uterine artery PI > or = 95(th) centile (OR, 2.0; 95% CI, 1.07-3.74) and low PAPP-A (OR, 0.43; 95% CI, 0.20-0.93). Increased uterine artery PI was the only independent factor in the prediction of placental abruption (OR, 8.49; 95% CI, 2.78-25.94). The combination of uterine artery PI and maternal history of pre-eclampsia/hypertension was better than was using uterine artery Doppler alone in predicting pre-eclampsia. Similarly, for the prediction of SGA < or = 5(th) centile, combining uterine artery Doppler and maternal serum PAPP-A was better than was uterine artery Doppler alone. In both cases, the difference approached statistical significance. CONCLUSIONS: The combination of maternal history with abnormal uterine artery Doppler and low PAPP-A level at 11-14 weeks achieves better results than does either test alone in the prediction of pre-eclampsia and SGA.

Pharmacokinetics of oral cefatrizine in pregnant and non-pregnant women with reference to fetal distribution.

OBJECTIVE: To investigate the effect of gestation on the pharmacokinetics of orally administered beta-lactams, choosing cefatrizine as the model antibiotic. SETTING: A tertiary teaching hospital. DESIGN: Prospective study. METHODS: In 20 women with affected fetuses, 17 by beta-thalassemia major and 3 with congenital malformations, termination of gestation between 19 and 24 weeks was induced by intra-amniotic administration of prostaglandin F(2)(alpha). Pharmacokinetics of cefatrizine in maternal and fetal blood were studied after the administration of three 1 g doses of oral cefatrizine, every 12 h. Twenty female non-pregnant volunteers consisted the control group. RESULTS: Gestation was found to decrease substantially both cefatrizine oral bioavailability and maximum serum plasma concentration (42.8 and 44.5%, respectively) but increased elimination half-life. This effect can be attributed to a substantial increase of the apparent volume of distribution of cefatrizine in relation to a moderate increase of clearance that occurs during pregnancy. Fetal serum cefatrizine levels were lower for the first few hours after administration and then exceeded the corresponding maternal ones. CONCLUSIONS: Our results indicate that gestation decreases the oral bioavailability of cefatrizine. A delay in the maternal drug elimination compared to non-pregnant controls was more pronounced in the fetus.

Systemic lupus erythematosus - associated acute severe thrombocytopenia and leukopenia first presented in pregnancy.

We report a rare case of acute severe thrombocytopenia and leukopenia, which first presented at 37 weeks' gestation. Based on clinical as well as on laboratory findings the diagnosis of systemic lupus erythematosus was made. The patient was successfully managed with an emergency transfusion of 6 units of platelets and intravenous immunoglobulin infusion followed by methylprednisolone administration. A caesarean section was performed at 39 weeks. The neonate was not thrombocytopenic at birth, nor at the age of 1 month.

Embryo reduction versus expectant management in triplet pregnancies.

OBJECTIVE: In triplet pregnancies, to compare pregnancy outcome of expectant management with that after embryo reduction to twins. METHODS: Retrospective study of 255 trichorionic triplet pregnancies, of which 185 had embryo reduction to twins (reduced group) and 70 were managed expectantly (non-reduced group). RESULTS: Median birth weight was higher by about 500 g and gestation prolonged by about 3 weeks in the reduced pregnancies compared with the expectantly managed pregnancies (2300 vs. 1760 g; 36 vs. 33 weeks). The rates of preterm delivery were significantly lower in the reduced group (11.17 vs. 36.76% for delivery at < or = 32 weeks and 40.58 vs. 83.82% for delivery at < or = 35 weeks, reduced vs. non-reduced group). The percentage of infants born with low birth weight was significantly higher in the expectantly managed triplets (10.98 vs. 28.44% for birth weight < or = 1500 g and 68.55 vs. 92.89% for birth weight < or = 2500 g, reduced vs. non-reduced group). Total fetal loss was significantly higher in the reduced group than in the non-reduced group (15.41 and 4.76%, respectively) and the difference was mainly due to the higher miscarriage rate in the reduced group (8.11 vs. 2.86% in the non-reduced group). With the expected rates of handicap in preterm infants, we would anticipate 0.63% of severely handicapped children due to extreme prematurity in the reduced group and 1.64% in the non-reduced group. CONCLUSION: In triplet pregnancies, embryo reduction to twins significantly reduces the risk of severe preterm delivery and very low birth weight by about one-third, at the expense of a significant increase in total fetal loss, by about one-quarter. The procedure is likely to reduce the risk of having a severely handicapped child due to extreme prematurity.

Pregnancy outcome after multifetal pregnancy reduction.

OBJECTIVE: To study the effects of multifetal pregnancy reduction (MFPR) as a means to reduce the adverse outcome of multiple gestations. METHODS: This was a retrospective study evaluating the outcome of 334 multiple pregnancies after embryo reduction. RESULTS: In 313 multiple pregnancies in which MFPR was performed before 15 weeks, the rates of miscarriage, preterm delivery <33 weeks, preterm delivery <36 weeks and total fetal loss were 9.12%, 13.33%, 38.60% and 16.25%, respectively, and median gestational age at delivery was 35 weeks. There was a significant correlation between miscarriage and the finishing number of fetuses. In 185 triplets reduced to twins, miscarriage, preterm delivery <33 weeks, preterm delivery <36 weeks and total fetal loss occurred in 8.25%, 11.18%, 40.59% and 15.41% of cases, respectively, and median gestational age at delivery was 36 weeks. In the subgroup of 32 reduced triplet pregnancies that also had second-trimester amniocentesis, the risk of miscarriage (3.13%) was not significantly different from that in the rest of the group. Among 21 twin pregnancies that had selective termination at or after 15 weeks, the risk of preterm delivery <33 weeks was three times higher than in the group of 22 twin pregnancies with first-trimester procedures. CONCLUSION: MFPR resulted in at least one live neonate in 83.75% of cases and was effective in reducing the risks of pregnancy loss and severe prematurity in quadruplets and higher-order pregnancies. The risk of miscarriage increased with increasing finishing number of fetuses. In reduced triplets gestation was prolonged in comparison with average figures reported in the literature. In twin pregnancies selective termination in the first trimester carries a lower risk of severe preterm delivery and this emphasizes the need for first-trimester diagnosis.

Risk factors predisposing to fetal loss following a second trimester amniocentesis.

OBJECTIVE: To examine the influence of possible risk factors on fetal loss rate following amniocentesis. DESIGN: Retrospective analysis of case records between 1993 and 1998. SETTING: Fetal medicine unit of a large teaching hospital. POPULATION: One thousand and six women with singleton pregnancies formed the study group. Seven hundred and eight of them had bleeding during the current pregnancy before the procedure. while 298 had a history of three or more first trimester abortions and/or a second trimester miscarriage or termination of pregnancy. Four thousand and twenty-four women who had amniocentesis and had no risk factors served as controls. Both groups were also classified according to maternal age. Group 1:1,610 women aged 20-34 years; Group 2: 2850 women aged 35-39 years; Group 3; 570 women > 40 years. METHODS: Women of both groups underwent a second trimester amniocentesis between 16 and 21 weeks of gestation. Fetal losses following amniocentesis were examined in three time intervals: 1. in the first two weeks after the procedure; 2. up to the 28th week; 3. from the 28th week to term. RESULTS: There was a statistically significant difference in the fetal loss rate between women aged 20-34 years (2.54%) and those > 40 years (5.1%). Women with a history of vaginal bleeding during the current pregnancy had a higher fetal loss rate compared with controls (6.5% vs 2.8%), which corresponds to an odds ratio of 2.4 (95% CI 1.69-3.42). A similar difference was found between the group of women with a history of previous abortions/terminations and the controls (8% vs 2.8%): OR 3.03 (95% Cl 1.92-4.79). CONCLUSIONS: There is a higher risk of fetal loss following amniocentesis in women > 40 years of age compared with those aged 20-34 years. Bleeding in the current pregnancy, a history of three or more first trimester abortions, a second trimester miscarriage or termination of pregnancy seem to be significant predisposing factors for fetal loss after an amniocentesis.

Cervico-isthmic pregnancy: an extremely rare case diagnosed during labour.

This case report describes a cervico-isthmic pregnancy ending in a live vaginal birth at 37+2 weeks' gestation. The case remained undiagnosed throughout pregnancy when after a fairly normal labour a massive haemorrhage occurred. After an unsuccessful effort to control the bleeding conservatively, a total abdominal hysterectomy was carried out. During the operation the diagnosis of cervico-isthmic pregnancy was confirmed, which was in accordance with the pathology report.

False positive serum biochemical screening and subsequent fetal loss in women less than 35 years of age.

OBJECTIVE: To examine the fetal loss rate in women younger than 35 years of age following a false positive serum biochemical screening. DESIGN: Retrospective analysis of case records between 1991 and 1998. SETTING: Fetal medicine unit of a large teaching hospital. POPULATION: Four hundred and fifty-six women with singleton pregnancies and false positive serum biochemical screening for Down's Syndrome (study group). Nine hundred and twelve matched controls with true negative serum biochemical screening (control group). METHODS: Women of both groups had a second trimester serum screening for Down's Syndrome using alpha fetoprotein, human chorionic gonadotrophin (hCG) and unconjugated oestriol (uE3); and they also underwent genetic amniocentesis. RESULTS: The overall fetal loss rate in the study group was 5.3% (24/456), compared with 1.65% (15/912) in the control group RR 3.2, 95% CI 1.7-5.99; P < 0.001). The majority of fetal losses in the study group occurred after 28 weeks, while in the controls this happened between 24 and 28 weeks of gestation. CONCLUSIONS: A false positive serum biochemical screening in women under 35 years of age is associated with a threefold increased risk of subsequent fetal loss. However, most of fetal losses in this group occurred after 28 weeks, indicating that intensive antepartum fetal surveillance could improve the perinatal outcome.

Use of misoprostol for the termination of second trimester pregnancies.

Surgical termination of pregnancy is of high risk for the woman's health and safe medical ways are required. The use of prostaglandins may substantially reduce this risk. The efficacy and safety of misoprostol as a medication for the termination of the second trimester pregnancies were studied. During a 15-month period ninety-eight healthy pregnant women (13-24 weeks) wishing to terminate their pregnancy due to medical reasons participated voluntarily in this study. Misoprostol was administered 400 microg per os and 400 microg vaginally. Dose was repeated every 6 hours until adequate contractions and cervical ripening were achieved. Outcome measures included successful termination rates, mean expulsion time and side effects of the medication. The efficacy of the method was as high as 91.8% (90/98 cases 95%, CI 86-97%). Mean expulsion time was 10.2 h (range 3-23.4 h) for primigravida and 9.2 h (range 2.5-22.2 h) for multigravida. In 9 cases (9.2%) placenta remnants and in 8 (8.2%) placenta retention were found. Most common side effect was shivering in 17.3% of cases, vomiting and nausea (10.2%), headache and dizziness (7.1%), abdominal pain (79.6%), while diarrhea was noticed in 4.1%. The high efficacy and low incidence of side effects make misoprostol a useful alternative method for medical termination of second trimester pregnancies.