Preterm premature rupture of membranes in singleton vs twin pregnancies: The latency periods and the clinical outcomes revisited.

Our objective was to compare the latency periods after preterm premature rupture of membranes (PPROM) and determine its subsequent impact on maternal and fetal outcomes for singleton and twin gestations > 24 weeks' and ≤ 34 weeks' gestation. Delivery in the first 72 h after the rupture of membranes was observed to be more frequent in the twin group (RR 1.98, 95% CI 1.06-3.73, p = 0.03); whereas the overall median latency periods were comparable (p = 0.06). Singleton pregnancies had shorter latency periods after 28 gestational weeks by comparison to the latency periods before 28 weeks. Gestational age of rupture of membranes and delivery and latency periods were comparable between spontaneous twin pregnancies and twin pregnancies after assisted reproductive technologies (ART). As a conclusion, singleton and twin pregnancies had similar outcomes after PPROM. The first 72 h is especially important for the outcome of twin pregnancies at when the delivery risk is high.

Evaluation of uterine perfusion in postmenopausal women receiving hormone replacement therapy.

OBJECTIVES: The authors evaluated uterine perfusion in postmenopausal women receiving hormone replacement therapy (HRT) by using transvaginal Doppler ultrasonography. MATERIALS AND METHODS: A total of 60 postmenopausal women receiving HRT were included in this prospective case control study. The patients were divided into two groups. The study group received HRT for at least one year. Uterine perfusion was evaluated by transvaginal Doppler ultrasonography and pulsatility index (PI) and resistance index (RI) of uterine arteries were also recorded with a 5-7.5 MHz transvaginal probe. All patients gave informed consent to the study. Statistical analyses were carried out by using the statistical packages for SPSS 15.0 for Windows. RESULTS: Demographic characteristics of the cases showed no statistically significant difference between the groups. There was a statistically significant difference between PI and RI of uterine arteries. In the study group PI and RI were lower than in the control group. As the duration of HRT use was prolonged, a decline in PI and RI increased (p < 0.05). CONCLUSION: The current study showed that HRT has positive effects on uterine blood flow in postmenopausal women and may be evaluated by transvaginal Doppler ultrasonography.

High frequency of thrombophilic disorders in women with recurrent fetal miscarriage.

OBJECTIVES: Our purpose was to examine whether genetic thrombophilias are etiological factors for recurrent fetal miscarriage or not. STUDY DESIGN: We compared the rate of thrombophilic anomalies in women with unexplained recurrent fetal miscarriages to the rate of age-matched women with successful pregnancies as a case-control study. RESULTS: A total of 101 consecutive patients with 102 age-matched controls were included in the study. The rate of Factor V (FV) Leiden mutation, Factor (F) II mutation, protein S, protein C, antithrombin III deficiencies and overall thrombophilia in patients with recurrent fetal loss was significantly higher than the frequencies in control patients. CONCLUSION: Women with recurrent fetal miscarriages have an increased incidence of thrombophilia. Genetic thrombophilias may be one of the major etiological factors for recurrent abortion and fetal demise.

Hyperprolactinemia of pregnancy is not associated with increased in vivo platelet activity and shortened in vitro bleeding times.

The aim of the study is to investigate whether platelet activity is increased by hyperprolactinemia during pregnancy as reflected by beta-thromboglobulin level. Forty-eight healthy, pregnant, and 30 healthy, non-pregnant women were investigated with respect to platelet count, collagen/ADP and collagen/epinephrine closure times, beta-thromboglobulin and prolactin levels. The comparison of the variables between the two groups was made by Mann-Whitney U test. The correlation analyses were performed by Spearman's rank correlation test. Our results revealed that platelet counts, collagen/ADP and collagen/epinephrine closure times and beta-thromboglobulin showed no statistically significant differences between pregnant and non-pregnant women. We found no significant correlation between prolactin and collagen/ADP closure time (r = 0.175), between prolactin and collagen/epinephrine closure time (r = -0.112) and between prolactin and beta-thromboglobulin (r = 0.220) in pregnant women. Our findings suggest that platelet activity is comparable during pregnant and non-pregnant states and there is no significant effect of prolactin on platelet function in vivo as reflected by beta-thromboglobulin level.

Acute fatty liver of pregnancy after aspirin intake.

Acute fatty liver is a rare but fatal complication of pregnancy. Here we describe a patient presenting with stupor and jaundice after aspirin intake at 35 weeks of gestation. Supportive management and delivery resulted in uneventful discharge of the patient and the newborn. Differential diagnosis and management of this condition are discussed.

Prenatal diagnosis of ranula at 21 weeks of gestation.

A fetal sublingual cystic lesion was diagnosed by routine prenatal ultrasonography at 21 weeks of gestation and followed up until term in a tertiary care center. Fetal growth was normal as was the amniotic fluid volume. Ex utero intrapartum treatment was performed and the cyst was aspirated to allow breathing and swallowing during planned Cesarean section. The cyst was totally excised when the newborn was 27 days of age and histological examination revealed a mucous cyst of the mouth floor.

Prenatal diagnosis of laryngeal atresia.

Prenatal diagnosis of congenital atresia of the larynx is difficult but is possible by the findings of increased lung echogenicity and size coexisting with fetal ascites in ultrasonography. Sonographic findings may not always be typical. We report on a case of congenital laryngeal atresia diagnosed prenatally by the findings of fetal hydrops and hyperechogenic lungs. Our case presented with oligohydramnios. We also review syndromes that demonstrate laryngeal anomalies.

The effect of steroids on the biophysical profile and Doppler indices of umbilical and middle cerebral arteries in healthy preterm fetuses.

OBJECTIVE: To examine the effect of antenatal steroids on the biophysical profile and the Doppler parameters of umbilical and middle cerebral arteries of healthy fetuses. STUDY DESIGN: Thiry-five singleton pregnancies between the gestational ages of 28 and 34 weeks, who received two consecutive doses of betamethasone 24h apart to accelerate pulmonary maturation were prospectively studied. Fetal biophysical profile and Doppler assessment were performed at 0 (pre-steroid), 24, 48, 72, 96 and 120 h after the administration of first dose. We compared the percentage of the fetuses with biophysical parameters present for each of the five components of the biophysical profile and the Doppler indices, using Cochran's Q-test, Friedman's test and one way analysis of variance of repeated measures where appropriate. The statistical significance was defined as P<0.05. RESULTS: The mean delivery time was 36.9(+/-1.8) weeks. There was a statistically significant difference in the frequency of the following findings in the pre- compared to post-steroid measurements: absence of body movements (48 h, P<0.05), non-reassuring fetal heart rate tracings (24, 48 and 72 h, P<0.05) and absence of breathing movements (24, 48 and 72 h, p<0.05). Initially none of the biophysical profile score was

Chromosomal mosaicism in a pregnant woman treated with acyclovir for herpes simplex encephalitis.

At 17th week of pregnancy, a 28-year-old woman was diagnosed as having herpes simplex encephalitis and treated with intravenous acyclovir. Follow-up by the serial ultrasound examinations, intrauterine growth retardation (IUGR) was found. During the course of disease, cordocentesis was performed to evaluate the risk of the disease and the infant's chromosomal constitution. No herpes simplex virus infection on cord blood sample was observed; however, chromosomal analysis revealed: 46,XX/47,XX,+2/47,XX,+11/47,XX,+19/48,XX,+11. After termination of pregnancy, the fetus was found as having ventricular septum defect. The presence of the triploid cell lines mocaicism involving chromosome 2 and 19 were confirmed by the analysis of fetal skin tissues. No attributable finding to herpes simplex virus infection and acyclovir treatment was found, and the presence of the triploid cell lines mocaicism were appeared to be purely coincidental.

Middle cerebral artery Doppler velocimetric deceleration angle as a predictor of fetal anemia in Rh-alloimmunized fetuses without hydrops.

OBJECTIVE: The purpose of this study was to evaluate the screening performance of a new middle cerebral artery Doppler velocimetric index for the prediction of fetal anemia. STUDY DESIGN: Doppler velocimetry of the middle cerebral artery was performed before cordocentesis in 24 Rh-alloimmunized fetuses without hydrops on 52 occasions. The angle between the line describing the average slope during the diastolic phase of the cardiac cycle and the vertical, the middle cerebral artery standardized deceleration angle, was measured. The deceleration angle values were expressed in multiples of the median for gestational age. The screening performances of deceleration angle for the prediction of anemia (difference between expected mean hemoglobin level and measured value >/=2 g/dL) and severe anemia (hemoglobin deficit >/=5 g/dL) were determined. RESULTS: The mean (+/-SD) gestational age at cordocentesis was 28.6 +/- 5.7 weeks' gestation. The risk of fetal anemia increased with decreasing deceleration angle values. The sensitivity and false-positive rate for the detection of anemia in cases with no previous transfusions (one measurement per patient) were 72.0% and 13.3%, respectively; among those with one previous transfusion the values were 90.0% and 0.0%, respectively. For severe anemia the corresponding values were 100% and 0%, respectively, among those with no previous transfusions and 100.0% and 16.7%, respectively, among those with one previous transfusion. There was no risk of severe anemia when the angle was >0.9 multiples of the median. The risk of anemia was significantly reduced with an angle greater than the median for gestational age (deceleration angle >1.0 multiples of the median; relative risk, 0.09; 95% confidence interval, 0.02-0.37). The risk was significantly increased with an angle less than the median for gestational age (deceleration angle <1.0 multiples of the median; relative risk, 30.0; 95% confidence interval, 5.9-158.4). CONCLUSION: The risk of fetal hydrops is remote in the absence of severe anemia. With a new Doppler velocimetric index in the middle cerebral artery the risk of severe anemia was found to be low when the deceleration angle was >0.9 multiples of the median. Anemia can also be predicted with this index. The high sensitivities and acceptable false-positive rates support the potential clinical applicability of the method to reduce the reliance on cordocentesis in Rh alloimmunization. Our findings appear to validate the utility of the deceleration angle for the prediction of fetal anemia.

Neonatal morbidity and mortality associated with maternal HELLP syndrome.

The syndrome of hemolysis, elevated liver enzymes and low platelet count (HELLP syndrome) is a severe form of preeclampsia and eclampsia. To compare the impact of HELLP syndrome and hypertension in pregnancy (HIP) on neonatal morbidity and mortality, 11 infants born to mothers with HELLP syndrome were recruited between 1993 and 1997 from neonatal records. They were compared to 11 infants born to mothers with HIP and 11 control infants born to healthy mothers matched for gestational age, postnatal age and gender. Cesarean section rate was higher in the HELLP group than in the controls (p < 0.05). HELLP group infants had lower Apgar scores (54.5% < 1 at 5th min), than controls (9.1%) (p < 0.05). Both HELLP and HIP group infants showed a higher incidence of intrauterine growth retardation (63.6% and 54.5%, respectively) than the controls (9.1%) (p < 0.05). The incidence of respiratory distress syndrome (RDS) was similar in HELLP and HIP groups and was greater than that in controls (p = NS). Additionally, the neonatal death rate was the highest in the HELLP group (p = NS).

Prenatal sonographic features of embryonal rhabdomyosarcoma.

We describe a case of fetal rhabdomyosarcoma detected during the third trimester of pregnancy by prenatal sonography. At 33 weeks' gestation, sonography performed because of suspected polyhydramnios showed a solid mass of 120 x 54 mm arising from the anterior wall of the fetal thoracic cage. Another mass within the left maxillary area which originated from the left orbital floor was also detected. In the abdomen, there were multiple round masses in and around the liver. As the previous scan at 28 weeks had appeared normal, the multiple masses which became visible and enlarged rapidly in different locations led us to believe that there was fetal cancer. The most likely diagnosis was rhabdomyosarcoma (which was later confirmed), because it is the most prevalent soft-tissue tumor in children and may develop within or outside muscle anywhere in the body and at any age. Two other reported cases which were detected by prenatal ultrasound examination are also discussed.

A new splenic artery Doppler velocimetric index for prediction of severe fetal anemia associated with Rh alloimmunization.

OBJECTIVE: We developed a new Doppler index for the noninvasive prediction of severe fetal anemia by means of Doppler velocimetry of the main splenic artery. STUDY DESIGN: Doppler velocimetry of the main splenic artery was performed in 85 healthy fetuses and in 22 nonhydropic study case patients (41 measurements) at risk for anemia from Rh sensitization. The deceleration angle between the line describing the average slope during the diastolic phase of the cycle and the vertical axis was measured and expressed in multiples of the median (MoM) for gestational age. Severe anemia was defined as a hemoglobin deficit (mean hemoglobin for gestational age minus measured hemoglobin) >/=5 g/dL. Anemia overall was defined as a hemoglobin deficit >/=2 g/dL. RESULTS: Mean gestational age at cordocentesis was 28.6 weeks. Severe anemia was noted on 7 occasions (12.6%) and anemia was noted on 21 (51.2%) occasions. There was a significant correlation between deceleration angle and hemoglobin deficit >/=2 g/dL (r = 0.5763, P <.0001) and also with hemoglobin deficit >/=5 g/dL (r = 0.6418, P <.0001). At deceleration angles <0. 90 MoM, a 90.5% sensitivity and a 30% false-positive rate were achieved for anemia detection. At a threshold deceleration angle of <0.60 MoM, the sensitivity for severe anemia was 100%, with an 8.8% false-positive rate. CONCLUSION: We report a new and sensitive Doppler velocimetric technique for predicting severe anemia. By means of splenic artery velocimetry, all cases of severe anemia could be identified before the development of hydrops, with a >91% reduction in the rate of cordocentesis.

Rh disease: intrauterine intravascular fetal blood transfusion by cordocentesis.

A total of 49 cordocenteses, including 40 intrauterine intravascular fetal blood tranasfusions, were performed in 30 pregnancies complicated by red cell isoimmunization. Transfusions were started at 19-33 weeks' gestation and repeated up to five times, at one-to-four week intervals. The volumes of transfused blood were 20-110 ml, hematocrits were 58-82 percent and the rate of transfusions was 1-15 ml/min. The pretransfusion fetal hemoglobins were 3.5-11.6 g/dl and the posttransfusion fetal hemoglobins were 7.5-15.6 g/dl. There were three intrauterine deaths and two neonatal deaths. The overall survival rate was 83.3 percent including all cordocenteses. The survival rate for the intrauterine transfusions was 81 percent.

Fetal splenic size in anemia due to Rh-alloimmunization.

OBJECTIVE: To determine whether fetal splenic enlargement predicts anemia in Rh-alloimmunized nonhydropic singleton fetuses. METHODS: Splenic circumference was measured before funipuncture in 21 singleton pregnancies on 47 occasions. The spleen was imaged in an axial section of the fetal abdomen close to the level used for measurement of the abdominal circumference. The splenic length and width were measured and the circumference calculated by the formula (length and width x 1.57). One measurement per patient was used for each analysis. Splenic circumference was measured and expressed as multiples of the normal median (MoM) for gestational age. One hundred twenty-one cases were used to provide cross-sectional normative data. The expected median splenic circumference values were derived from a normal group. Fetal anemia was defined as hemoglobin deficit, ie, mean hemoglobin concentration for gestation minus the measured value. Anemia was defined as hemoglobin deficit exceeding 2 g/dL, and severe anemia as hemoglobin deficit exceeding 5 g/dL. Receiver operator characteristics curves for the prediction of anemia using different splenic circumference (MoM) values were constructed. RESULTS: Splenic circumference was an excellent predictor of severe anemia in cases with no prior transfusion: sensitivity 100% and specificity 94.7% (area under the curve = .97, P < .03). The measurement did not correlate significantly with severe anemia in the group with prior transfusion (area under the curve = .73, P = .19). CONCLUSION: Splenomegaly is sensitive for the detection of severe anemia in nonhydropic Rh sensitized cases without prior transfusion. The splenic enlargement could be explained by extramedullary erythropoiesis.

The clinical predictors of intrauterine fetal death.

Five hundred and thirteen (513) patients with intrauterine fetal death managed between 1983 and 1990 at Hacettepe University Hospital were analyzed retrospectively. Fetal death rate was 20.5/1,000 deliveries during the study period. The mean age of the mothers at diagnosis was 27.6 years. Of the 326 multigravida patients, 113 (34.6%) had a history of abortion and 113 had a history of previous intrauterine fetal death. The leading causes of intrauterine fetal death in this series were maternal hypertension in 167 patients (32.5%) followed by abruptio placentae in 38, Rh incompatibility in 30 and congenital anomalies in 30 patients. However, in 175 patients (34.1%), the cause of intrauterine fetal death could be explained. Three mothers were lost: one from pulmonary embolism complicating deep venous thrombosis, one from heart failure due to rheumatic disease, and one from cerebral injury following a traffic accident. The patients with a history of fetal demise should be managed under high risk category with close antepartum surveillance, especially in the last trimester, so as to reduce intrauterine fetal deaths which are mostly attributable to preventable causes.

Elevated second trimester human chorionic gonadotropin level associated with adverse pregnancy outcome.

OBJECTIVE: Our purpose was to determine whether unexplained elevations in maternal serum human chorionic gonadotropin in the second trimester may be associated with adverse pregnancy outcome. METHOD: Between April 1992 and April 1995, 610 pregnant women undergoing second trimester triple marker screening for Down syndrome who delivered at our institution were evaluated. Eighty-one women with a hCG level greater than 2.0 multiples of the median (MoM) were included in the study group while 481 women with hCG levels < 2.0 MoM served as controls. Pregnancies with fetal chromosomal and structural anomalies and maternal serum alpha-fetoprotein levels greater than 2.0 MoM were excluded from the study. Pregnancy outcomes were obtained from hospital delivery records. Statistical analysis were performed by Student's t-test; odds ratios and 95% confidence intervals were also calculated. RESULTS: Women with elevated human chorionic gonadotropin levels showed an increased risk for preeclampsia (odds ratio (OR): 5.93, 95% confidence interval (CI): 1.97-15.88), intrauterine growth retardation (OR: 5.34, 95% CI: 2.14-13.34), preterm delivery (OR: 5.66, 95% CI: 3.22-9.98), and preterm premature rupture of membranes (OR: 3.15, 95% CI: 1.23-8.07). CONCLUSION: Unexplained elevation of human chorionic gonadotropin in the second trimester appears to be associated with adverse pregnancy outcome.