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.

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.

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.

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.

Bilateral ovarian fibromatosis presenting with ascites and hirsutism.

BACKGROUND: Ovarian fibromatosis is a very rare nonneoplastic disease. Due to the rarity and atypical clinical presentations, they may give rise to a misdiagnosis of malignancy and unnecessary extensive surgical interventions. Literature lacks definitive data about this rare disease and its preoperative evaluations. MRI together with the intraoperative frozen section may help us to define the benign nature of the disease. In this report, we aimed to review the literature and give a highlight to the gynecologic oncologists about this rare disease. CASE HISTORY: A 19-year-old female patient admitted to our hospital with the complaints of menstrual irregularity, hirsutism, and increased abdominal girth. Physical examination revealed bilateral ovarian mass, hirsutism, and ascites. Serum CA-125 levels were slightly elevated. Preoperative MRI study showed bilateral hypointense lobulated ovarian masses. With the initial diagnosis of ovarian tumor, we performed explorative laparotomy and excised both masses. Final pathology was reported as bilateral ovarian fibromatosis. CONCLUSION: Ovarian fibromatosis commonly presents with ascites and solid pelvic mass and can be misdiagnosed as a malignant ovarian tumor. In young patients, clinicians should consider ovarian fibromatosis in differential diagnosis of pelvic mass. Preoperative MRI findings and intraoperative frozen examination may be used to avoid unnecessary aggressive surgical management.