Effect of atracurium or pancuronium on the anemic fetus during and directly after intravascular intrauterine transfusion. A double blind randomized study.

BACKGROUND: To determine the effect of atracurium or pancuronium on onset and duration of fetal paralysis, movements and heart rate parameters directly after transfusion, using computer analyzed fetal heart rate recording (c-FHR). METHODS: Double blind randomized study of 23 RhD alloimmunized pregnant women requiring an intravascular intrauterine fetal blood transfusion (IUT) between 24 and 36 weeks. Atracurium was injected in 11 fetuses at 17 IUT's and pancuronium in 12 fetuses at 19 IUT's. For statistical analysis the Mann-Whitney test was used. RESULTS: No statistical differences were found in fetal heart rate and movements between both groups before transfusion. The fetal movements returned more rapidly in the atracurium group when compared to the pancuronium-group (median 24 vs. 57 min, range 6-55 vs. 4-220; (p<0.02). Fetal movements did not hamper the procedure in any case. The atracurium group showed significantly more fetal movements (p<0.01), more accelerations (0<0.05) but no significant reduction of fetal heart rate variability directly after transfusion which was in direct contrast to the pancuronium group. CONCLUSIONS: Neuromuscular blockade with atracurium produces sufficient paralysis for intrauterine transfusion with minimal disturbance of the parameters used to monitor fetal wellbeing after the procedure. Although the routine use of fetal paralysis during IUT may be questionable, we believe that when it is necessary the use of atracurium is the better choice.

Pathophysiology and treatment of fetal anemia due to placental chorioangioma.

Placental chorioangiomas occur in 1% of pregnancies. Large chorioangiomas may cause serious complications such as fetal anemia, hydrops and fetal death. In this case report, a pregnancy complicated by a large placental chorioangioma is described. Severe fetal anemia without the occurrence of hydrops fetalis was suspected using ultrasound and Doppler examinations. Successful intrauterine blood transfusion was performed, with an unusually large amount of blood needed to obtain an adequate rise in fetal hematocrit. Two weeks later, at 32 weeks, the infant was born in good condition. In pregnancies with large chorioangiomas, we advise regular ultrasound and Doppler examinations, with the aim of detecting fetal anemia before hydrops develops. When anemia is suspected, fetal blood sampling is indicated and intrauterine transfusion therapy may be beneficial to preserve fetal health until maturity is reached.

Cervicovaginal fetal fibronectin concentrations: predictive value of impending birth in postterm pregnancies.

OBJECTIVE: To determine the predictive value of cervicovaginal fetal fibronectin (fFN) concentrations > or =50 ng/ml for spontaneous onset of labour within 3 days in pregnancies of 41 weeks gestation or more. STUDY DESIGN: In the Department of Obstetrics, Leiden University Medical Centre, and of the Diaconessen Hospital, Voorburg (The Netherlands), 126 cervicovaginal secretions of fFN, from 80 consenting women between 287 and 304 days gestation were collected. Pregnant women underwent sterile speculum examinations for cervicovaginal sampling from the 41st week onwards. The fFN concentration in these samples was determined with a quantitative solid-phase enzyme-linked immunosorbent assay. Concentrations of <50 ng fFN per ml were characterised as negative test results, meaning that spontaneous delivery would not take place within 3 days, and those of > or =50 fFN ng/ml were taken as positive test results. Sensitivity and specificity of the fFN test were calculated for predicting spontaneous birth. Parametric and nonparametric tests were used for evaluating differences and correlations. RESULTS: Spontaneous delivery took place after 2.5+/-2.5(SD) days with fFN values > or =50 ng/ml and after 4.7+/-3.6 days with fFN concentrations <50 ng/ml (P<0.001). Sensitivity and specificity of the fFN test predicting spontaneous onset of labour within 3 days, were 0.71 [95% confidence interval (CI) 0.58-0.86] and 0.64 (95% CI 0.48-0.78). If fFN > or =50 ng/ml then a spontaneous onset of labour is more likely to occur within 3 days (odds ratio 4.5 (95% CI 1.8-11.3). CONCLUSIONS: The fFN test does not predict accurately enough whether or not birth will take place within 3 days of sampling. Nevertheless, the higher odds for spontaneous delivery within a few days when the test is positive may be of use in planning adjusted induction of labour.