Amniotic fluid "sludge"; prevalence and clinical significance of it in asymptomatic patients at high risk for spontaneous preterm delivery.

INTRODUCTION: The aim of our study is to determine prevalence and clinical significance of the presence of amniotic fluid "sludge" among asymptomatic patients at high-risk for spontaneous preterm delivery, prospectively. MATERIAL AND METHODS: In our study, 99 patients at high risk for spontaneous preterm delivery were evaluated for the presence of amniotic fluid sludge with transvaginal ultrasonography at 20-22, 26-28, and 32-34 gestational weeks, prospectively; between August 2009 and October 2010 in Hacettepe University Hospital. And, these patients were followed up for their delivery weeks and pregnancy outcomes. We defined the high-risk group as the patients possessing one or more of the followings; a history of spontaneous preterm delivery, recent urinary tract infections, polyhydramnios, uterine leiomyomas, müllerian duct anomalies, and history of cone biyopsy or LEEP. Patients with multiple gestations, placenta previa, fetal anomalies, or symptoms of preterm labor at first examination were excluded. We have obtained ethical board approval from Hacettepe University (16.07.2009-HEK/No:09-141-59). RESULTS: The prevalence of amniotic fluid sludge in the study population was 19,6% (18/92). The rates of spontaneous preterm delivery at <37 weeks of gestation were 66,7% (12/18), within the patients with sludge and 27,0% (20/74) within the patients without sludge. Patients with sludge had a higher rate of spontaneous preterm delivery (p = 0.002). A higher proportion of neonates born to patients with amniotic fluid sludge had a neonatal morbidity (50% (9/18) vs. 24,3% (18/74), p = 0.044) and died in the perinatal period, (p = 0,013) than those born to patients without sludge. When we combined sludge and cervical lenght (CL) (<25 mm) and used it as a screening test to identify women at risk for preterm delivery; it catched more women with preterm delivery, (p = 0.000). While sensitivity of sludge was 37,5%, and sensitivity of CL was 34%, sensitivity of "sludge positive or CL ≤25 mm" was 56% for preterm birth (PTB) in high-risk group. CONCLUSIONS: The prevalence of amniotic fluid sludge is 19,6% and "sludge" is an independent risk factor for spontaneous preterm delivery among asymptomatic patients at high-risk for spontaneous preterm delivery. PTB is by far the leading cause of infant mortality, and prevention of PTB has been an elusive goal. When sludge added to screening, we can catch more PTB.

Integration of three-dimensional ultrasonography in the prenatal diagnosis of amniotic band syndrome: A case report.

Amniotic band syndrome is a rare disorder which is thought to be caused by early rupture of the amniotic membrane. The extent of the disease may vary from minor digital amputations to severe lethal anomalies. For many years in routine clinical practice, this syndrome has been diagnosed with two-dimensional ultrasonography. Evolving imaging techniques by means of three-dimensional ultrasonography gives the chance of early and accurate diagnosis of this devastating anomaly. By integrating three-dimensional ultrasonography to the suspected findings diagnosed in the two-dimensional ultrasonography allows us to predict possible outcomes and provides convenience in counselling. Herein we present a case of amniotic band syndrome diagnosed at 19 weeks of gestation with three-dimensional ultrasonography and pregnancy was terminated in the 20th week. Using three-dimensional ultrasonography in certain suspected foetal anomalies may provide the early diagnosis and more accurate knowledge about extent of the disease.

Ultrasonographic measurement of amniochorionic membrane in asymptomatic pregnant women is not a useful tool for preterm birth prediction.

AIM: The objective of this study was to determine the accuracy of ultrasonographic measurement of amniochorionic membrane thickness (AMT) in the prediction of preterm birth among an asymptomatic pregnant population. METHODS: One hundred and ninety consecutive singleton pregnant women presenting for prenatal care between May 2010 and August 2011 were recruited for the study. AMT of the patients was measured once between 18 and 22 weeks of gestation and then again between 28 and 32 weeks of gestation with transabdominal ultrasound. The results of measurements were recorded and compared with the perinatal outcome related to prematurity. RESULTS: Thirteen of the 190 births were preterm. The mean AMT of the pregnant women who delivered at term were 0.79 ± 0.23 mm in the second trimester and 0.88 ± 0.27 mm in the third trimester. The mean AMT of pregnant women who delivered preterm were 0.77 ± 0.27 mm in the second trimester and 0.91 ± 0.20 mm in the third trimester. There were no statistically significant differences between the second and third trimester AMT of the preterm delivery group and term delivery group (P = 0.542 and P = 0.448, respectively). CONCLUSION: In this study, ultrasonographic measurement of fetal membranes was not found to be a useful marker for prediction of preterm birth. The findings of our study may help in understanding ultrasonographic changes in fetal membranes in normal pregnancies.

Prenatal diagnosis and clinicopathologic examination of a case with diastematomyelia.

Diastematomyelia is a rare form of spinal dysraphism. Here the spinal cord was split into two with a bony or cartilaginous spur, resulting in formation of two hemicords. The prenatal diagnosis of diastematomyelia is possible with ultrasonography. The unique finding is the appearance of echogenic focus within the spinal canal. This condition may not have any clinical sign during prenatal and early years of life but as the child grows, serious neurologic manifestations may occur, commonly termed the "tethered cord syndrome". Here, we report a case of diastematomyelia in which a careful antenatal imaging was performed and postnatal pathologic examination confirmed the diagnosis.

Prenatal echocardiographic diagnosis of cardiac right/left axis and malpositions according to standardized Cordes technique.

OBJECTIVE: The aim of this study was to evaluate distinguishing the right/left side of the fetus, cardiac axis and position according to the standardized Cordes technique in 20 cases with cardiac malposition. METHODS: We studied retrospectively 1536 cases whose fetal echocardiographic examinations were performed between 1999 and 2006 in prenatal cardiology unit. Among these, cardiac malpositions were determined in 20 cases. The cardiac axis and position were determined according to the Cordes technique. All cases were followed-up by serial fetal echocardiograms until birth or intrauterine death occurred. In cases of intrauterine death, an autopsy was performed. After birth, physical and echocardiographic examinations were done and prenatal and postnatal diagnoses were compared. RESULTS: Of 1536 fetal echocardiograms performed, 144 revealed congenital heart diseases (9.4%), among these cases 20 were diagnosed with cardiac malposition. Of cases with cardiac malposition, 16 had congenital heart disease, and four had extracardiac malformation. There were six cases of isolated dextrocardia, three cases of situs inversus totalis, six cases of situs ambiguous, and one case of situs inversus with isolated levocardia. Of four cases with extracardiac malformations, two cases had mesoposition, one had dextroposition, and one had extreme levoposition. In six cases the autopsy findings were the same as that their prenatal echocardiographic findings. When postnatal echocardiographic results of the remaining cases with cardiac malposition due to congenital heart disease were compared with prenatal diagnoses, the same echocardiographic findings were verified. CONCLUSION: The fetal right/left axis must be determined correctly for the accurate diagnosis of cardiac malpositions. Therefore, we recommend that Cordes technique provides a simple and reliable determination of the fetal right/left axis and fetal situs.

Fetal arterial and venous Doppler in growth restricted fetuses for the prediction of perinatal complications.

Fetal arterial and venous Doppler is a useful tool for the monitoring of growth restricted fetuses. Our aim in this study was to compare outcomes when fetuses were grouped according to the combinations of the Doppler results and also according to each vessel Doppler. Deliveries during the period 2002-2008 were reviewed retrospectively and cases with a birth weight less than the 10th percentile were selected for the study. Cases with congenital malformations or chromosomal abnormalities were excluded. Cases were then grouped according to umbilical artery (UA), middle cerebral artery (MCA) and ductus venosus (DV) Doppler results. Two hundred fifty-five cases were selected for the study. The perinatal mortality rate was 9.8% (11 prenatal and 14 neonatal). In the presence of absent or reverse flow in UA, fetal death and neonatal complication rates were higher. In the fetuses having reverse or absent "a" wave, there were findings of metabolic deterioration. Absent-reverse UA end-diastolic flow increased the odds ratios of perinatal and fetal death, bronchopulmonary dysplasia (BPD), necrotizing enterocolitis (NEC), respiratory distress syndrome (RDS), and need for neonatal intensive care unit (NICU) (2.81, 5.94, 10.82, 5.79, 5.19, and 11.60, respectively). Absent/reverse "a" wave in DV increased the odds ratio of perinatal death, fetal death, neonatal death, RDS, and abnormal pH (19.89, 18.06, 12.50, 8.29, and 9.67, respectively). For prediction of fetal metabolic status, DV Doppler is a reliable tool. However, when perinatal complications are considered, this finding for intervention to delivery is a late point. Therefore, when reverse end-diastolic flow in the UA is observed, decision-to-delivery should be taken in order to avoid metabolic deterioration and increased postpartum death.

Perinatal outcomes of fetal abdominal cysts and comparison of prenatal and postnatal diagnoses.

INTRODUCTION: The differential diagnosis of an abdominal cyst can be challenging, and an accurate diagnosis is crucial for optimal antenatal management. The aim of this study was to compare the ante- and postnatal diagnoses of cases with abdominal cyst and to determine the diagnostic accuracy of ultrasonography. MATERIAL AND METHODS: A database review was performed regarding the diagnosis of fetal abdominal cyst covering the period 2002-2009. Structural characteristics and localizations of the cysts in the abdomen were recorded. Ante- and postnatal diagnoses were classified into systems according to the origin of the cyst and were compared. Perinatal outcomes were obtained for all cases. RESULTS: 71 cases with an abdominal cyst were identified. The mean gestational age at the time of diagnosis was 25 ± 5.1 weeks. In 9 cases, there were extra-fetal structural abnormalities, and in 5 cases a chromosomal abnormality was determined. Seven pregnancies were terminated. Overall spontaneous mortality was 11/64 (17%). In 12/64 cases (18%), the cyst resolved at birth. After birth, nearly half of the cases required surgical correction and of these, 20% died. Sensitivity, specificity and positive predictive value of ultrasonography in identifying the system of origin were 88.1, 95.7 and 92.0%, respectively, with a 4.1% false-positive rate. CONCLUSION: Incorporation of different disciplines in the counseling, management and postpartum follow-up is crucial. Postnatal physical examination of fetuses with an abdominal cyst will help to prevent unnecessary surgery.

Prenatal diagnosis of Jarcho-Levin syndrome in combination with inguinoscrotal hernia.

Jarcho-Levin syndrome is characterized by short trunk dwarfism associated with rib and vertebral anomalies. The syndrome encompasses a group of disorders with phenotypic and inheritance variations. Here we report a prenatally diagnosed patient with spondylocostal dysostosis (SCD) with accompanying congenital inguinoscrotal hernia. A 28-year-old pregnant women, gravida 4, para 3, was referred to our clinic with a diagnosis of wedging of fetal thoracal vertebra and kyphoscoliosis at 28 weeks of gestation. Upon evaluation, fetal vertebral wedging and kyphoscoliosis were confirmed with the addition of thoracic circumference below 3rd percentile, short thorax length, and mild pyelectasis. During follow-up, in utero inguinoscrotal hernia developed. Prenatal diagnosis of SCD is important to provide appropriate genetic counseling and to have an adequate setting for the delivery of the fetus.

Perinatal features and umbilical cord blood gases in newborns complicated with nuchal cord.

Presence of nuchal cord (NC) is associated with transient decrease of umbilical cord blood flow. However, the exact perinatal effect of presence of NC in a newborn is still under debate. The aim of this study was to evaluate the perinatal complications and umbilical cord blood gases of deliveries complicated with NC and summarize the associated literature. Gestational age-matched term singleton pregnancies complicated with NC (n=160) were compared with neonates without NC (n=160). Patients' files and Labor and Delivery Unit database were used to extract maternal age, gestational age, presence of NC, number of nuchal loops around fetal neck, intrapartum complications and umbilical cord blood gases. pH, pO2, pCO2, HCO3-, O2 saturation, and base excess were determined in all patients. Mean maternal age, mean gestational age, and birth weight were not significantly different between the two groups (p > 0.05). Occurrence of oligohydramnios, intrauterine growth retardation (IUGR), intrapartum abnormalities and Apgar scores < 7 at 1 minute were not significantly different between the groups (p>0.05). However, umbilical cord blood pH (7.32 vs. 7.30, p = 0.048), pO2 (37.4 +/- 18.1 vs. 31.7 +/- 14.4, p = 0.01) and O2 saturation (57.4 +/- 21.8 vs. 48.3 +/- 20.4, p = 0.005) were significantly lower in the NC group compared with the controls. Furthermore, the number of Apgar scores < 7 at 1 minute was significantly higher in neonates with multiple NC (28.1% vs. 9.2%, p = 0.007), and intrapartum abnormalities were more frequently seen in newborns with multiple NC (31.3% vs.15.6%, p = 0.04). The results of this study suggest that presence of single NC may negatively affect the umbilical cord blood gases without significant perinatal complications. However, multiple NC may also increase the development of intrapartum complications and lower Apgar scores. Perinatal effects of NC should be investigated with a large prospective study.

Endometrial osseous metaplasia: an evolving cause of secondary infertility.

OBJECTIVE: To present an endometrial osseous metaplasia case and reemphasize that the condition is a cause of secondary infertility. DESIGN: Case report. SETTING: Department of Obstetrics and Gynecology in a university hospital in Turkey. PATIENT(S): A 33-year-old multiparous woman was admitted to our institution with secondary infertility that had lasted for 2 years. She had experienced one first-trimester and one second-trimester abortion, 3 years and 2 years ago, respectively. On transvaginal sonography, a linear curvy echogenity was observed. INTERVENTION(S): Hysteroscopic examination revealed multiple bony spicules, extending perpendicularly from the posterior uterine wall in to the uterine cavity and occupying almost two thirds of the cavity. Thereafter, a resectoscopic excision of the bony spicules was performed. MAIN OUTCOME MEASURE(S): A normal endometrium and uterine cavity. RESULT(S): Two weeks after the operation, ultrasonographic evaluation was in the normal range, and the patient currently is trying to conceive spontaneously. CONCLUSION(S): Although the role of office hysteroscopy in the evaluation of infertile couple is still under debate, clinicians should keep this rare disorder in mind, especially in patients with a history of late abortion, and should evaluate such cases by hysteroscopy when sonographic features are encountered.

Posterior leukoencephalopathy syndrome as a cause of reversible blindness during pregnancy.

Cortical blindness is a rare and dramatic complication of pre-eclampsia. The precise nature of the pathogenesis of this condition has not previously been understood. Three preeclamptic patients with unremarkable previous medical history presented with acute blindness between the 28th and 33rd weeks of pregnancy. They were all diagnosed as posterior leukoencephalopathy syndrome (PLES). In all these patients, MRI study revealed the typical feature of gray-white matter edema localized to the temporo-parieto-occipital areas. Vision and MRI findings were restored in all patients after delivery. Although PLES has been described as a puerperal clinicoradiologic entity, it may be seen in preeclamptic-eclamptic patients during the pregnancy. Therefore neuro-imaging studies should be carried out in pregnant patients with visual disturbances in order to exclude PLES. Prompt diagnosis, immediate control of blood pressure, and elimination of possible causes resolves clinical and imaging findings.

Alcohol injection for the intrauterine treatment of chorioangioma in a pregnancy with transfusion resistant fetal anemia: a case report.

Chorioangiomas are usually small, clinically inevident, benign vascular lesions of the placenta, but larger ones may cause serious perinatal and neonatal complications. There is need for in utero intervention in these fetuses. Several interventions are described to relieve pathophysiologic insult on fetus. Alcohol injection is one of the therapeutic interventions. In this case, we present a patient with chorioangioma and early onset of hydrops fetalis and polyhydramnios at 24th week of gestation. Successful intratumoral injection of absolute ethyl alcohol relieved hydrops fetalis and polyhydramnios. Unfortunately, pregnancy ended at 28th week and a 1,330 g fetus was delivered.

Perinatal outcomes of spontaneous twins compared with twins conceived through intracytoplasmic sperm injection.

OBJECTIVE: To compare perinatal outcomes in spontaneous twins compared with those conceived by intracytoplasmic sperm injection (ICSI). DESIGN: Retrospective case-control study. PATIENTS: Cases consisted of 274 intracytoplasmic sperm injection twins, controls were 348 naturally conceived twins delivered between 1999 and 2003 in a tertiary hospital. MAIN OUTCOME MEASURES: Birth weight, gestational age at birth, cesarean delivery rate, perinatal mortality and morbidity, congenital anomalies, gestational diabetes and pregnancy induced hypertension. RESULTS: Preterm deliveries (76.6% vs. 64.1% <37 weeks and 19.7% vs. 13.2% <32 weeks) and low birth weight (73% vs. 60.3% <2500 g and 19.7% vs. 12.6% <1500 g) were significantly higher in the ICSI group compared with controls. Gestational diabetes mellitus (8% vs. 2.9%) and cesarean deliveries (95.2% vs. 77.6%) were more common in cases compared with the control group. There was a significantly higher rate of perinatal morbidity (16.4% vs. 7.8%) and mortality (8% vs. 2.6%) in ICSI twins. The incidence of congenital malformations diagnosed at birth was higher in cases (4.4%) compared with controls (0.9%) but the difference was not significant when adjusted for maternal age. CONCLUSION: Perinatal outcomes of twins after ICSI treatment are less optimal than naturally conceived twins.

Isolated noncompaction of left ventricular myocardium with fetal sustained bradycardia due to sick sinus syndrome.

Noncompaction of the ventricular myocardium is a rare congenital cardiomyopathy resulting from an arrest in normal endomyocardial embryogenesis. This disease is characterized by numerous and prominent trabeculations and deep intertrabecular recesses. It may be isolated or associated with other congenital heart diseases. The disorder is clinically accompanied by depressed ventricular function, systemic embolization and arrhythmias. Sustained bradycardia is infrequent in prenatal life and associated with maternal collagen vascular diseases, structural heart diseases or long QT syndrome. Herein we report a case of isolated noncompaction of left ventricular myocardium diagnosed in the first day of life and followed previously by serial fetal echocardiograms for the sustained sinus bradycardia. On postnatal electrocardiography, there was junctional escape rhythm due to profound sinus bradycardia, leading us to consider sick sinus syndrome. To our knowledge, this is the first case in the literature of isolated noncompaction of left ventricular myocardium with sustained bradycardia due to sick sinus syndrome.

Prenatal echocardiographic diagnosis of congenital heart disease: comparison of past and current results.

The increased experience in interpretation of fetal echocardiographic images may change the accuracy of fetal echocardiography in diagnosing fetal heart defects. We thus decided to evaluate the specificity and the sensitivity of our fetal echocardiographic examinations in diagnosing congenital heart disease, focusing especially on the outcome of complex cardiac pathologies. Between October 1999 and July 2003, 642 fetuses were followed until birth and underwent a postnatal reassessment of the cardiovascular system in our institution. These cases constitute our cohort. The postnatal reassessment was mainly done by echocardiography; some cases also had angiography. In case of intrauterine or postnatal death, an autopsy was performed. The prenatal and postnatal diagnoses were compared, and specificity and sensitivity of fetal echocardiography for congenital heart pathologies were determined. Among 45 affected pregnancies, 31 cases had complex and 14 had significant cardiac defects. The sensitivity of fetal echocardiography for cardiac anomalies was 93.3%; the specificity was 100%. Compared to our previous study, the sensitivity was remarkably improved (in our previous study sensitivity was 78% and specificity 100%). Echocardiography is a very useful and reliable tool in the evaluation of the fetal cardiovascular system, and has high sensitivity and specificity for congenital heart diseases.

Is Dandy-Walker malformation associated with "distal 13q deletion syndrome"? Findings in a fetus supporting previous observations.

We report on a fetus with a large deletion of the distal part of the long arm of chromosome 13, (del(13)(q14 --> qter)) congenital anomalies of the urinary system, lungs and extremities, and Dandy-Walker malformation (DWM). Although DWM has been associated with many chromosomal abnormalities and genetic syndromes, its relation to the distal 13q has been demonstrated recently. In 2002, McCormack et al., described two patients with deletions of the long arm of chromosome 13 who had multiple congenital abnormalities along with holoprosencephaly (HPE) and DWM. The phenotypic features and autopsy findings of a fetus with "distal 13q deletion syndrome" at 22 weeks gestation are discussed and comparison with the previous two cases is made. The findings support the previous hypothesis suggesting that haploinsufficiency at a locus within 13q22-33 due to microdeletions may be responsible for isolated DWM in some of the patients. Detailed examination of 13q (13q22-33) by means of conventional and molecular cytogenetic methods is necessary in cases with DWM.

Placental apoptosis in pregnancies with intrauterine meconium passage.

In this study we investigated the presence of placental apoptosis in pregnancies with intrauterine meconium passage. Placental tissue samples at term were obtained from 15 normal and 15 pregnancies with intrauterine meconium passage. Terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick-end labeling method was applied to confirm apoptosis in all placental samples. The mean apoptotic ratio was significantly higher in placentas of pregnancies with intrauterine meconium passage when compared with normal ones (0.37 +/- 0.06% and 0.29 +/- 0.07%, respectively; p < 0.01). The mean apoptotic ratios in trophoblastic and stromal cells were significantly higher in placentas of pregnancies with intrauterine meconium passage than normal placentas (0.47 +/- 0.10% and 0.36 +/- 0.11% [ p < 0.05] and 0.29 +/- 0.07% and 0.22 +/- 0.07% [ p < 0.05], respectively). Increased placental apoptosis in pregnancies with intrauterine meconium passage could be a causative factor in the pathophysiology of the disorder or a direct effect of meconium on placental cells.

Results and lessons learned from a small medical abortion clinical study in Turkey.

This article presents results from a small, introductory clinical study offering a simplified regimen medical abortion to women in Turkey. A total of 208 women from five sites were recruited from July 2000 through March 2001. All eligible consenting women were given 200 mg oral mifepristone at the clinic followed by 400 microg oral misoprostol 2 days later either at home or at the clinic. The overall success rate of 84.1% is lower than in previous studies of this regimen, and a surprisingly high proportion of women (9.1%) were diagnosed with incomplete abortion. In spite of the higher than expected failure rate, women expressed a high degree of satisfaction. Several challenges were faced during this study, providing valuable insights about ways to introduce medical abortion into new settings with the best chances for success.