Outcome of severely anaemic fetuses treated by intrauterine transfusions.

BACKGROUND: Fetal anaemia is a well-known complication of pregnancy, which might have an ominous effect on the course of pregnancy, labour and the child's development. OBJECTIVE: To assess the effect of the severity of fetal anaemia on the child's outcome. METHODS: A retrospective cohort study. Pregnancies treated by intrauterine transfusions for fetal anaemia at Sheba Medical Center (1996-2004) were divided into two groups: mild to moderate anaemia (fetal haematocrit >0.50 multiples of the median (MoM)) and severe anaemia (hydrops fetalis or fetal haematocrit < or =0.50 MoM). Data were retrieved from relevant obstetric and fetal medicine files. RESULTS: During the study period, 54 fetuses were treated by 154 (median 3; range 1-7) intrauterine transfusions for red cell alloimmunisation. The sensitising antigen was D in 70% of cases; 18/54 patients were sensitised to more than one antigen. Thirty-three of the 54 fetuses (61%) were in the severely anaemic category (haematocrit range 3-20%); six were hydropic. Twenty-one of the 54 fetuses (39%) were in the mild-moderate anaemic category (haematocrit range 20-37%). On prenatal evaluation, there were no sonographic markers of central nervous system abnormalities or intraventricular haemorrhage. There were no differences in the neonatal outcome between the two groups. Developmental outcome was available in 14/18 (78%) mild-moderate cases and 26/29 (89%) severe cases. There were no significant differences in motor development score, percentage of abnormal cognitive development, and percentage of children needing supportive therapy between the mild-moderate and severe cases. CONCLUSION: Neonatal and developmental outcome of fetuses treated for severe anaemia is comparable to cases of mild anaemia.

Management of Kell isoimmunization--evaluation of a Doppler-guided approach.

OBJECTIVE: To assess the role of peak systolic velocity in the middle cerebral artery (MCA-PSV) in the management of pregnancies complicated by Kell isoimmunization. METHODS: Sixteen fetuses were monitored by conventional protocol (Group 1) and eight fetuses by an MCA-PSV-guided protocol (Group 2). The conventional protocol included a weekly ultrasound evaluation and measurement of maternal anti-Kell titers every 4-6 weeks. In Group 2 Doppler assessment of the MCA-PSV was performed at intervals of 4 to 7 days and MCA-PSV>1.5 multiples of the median (MoM) was considered as an indication for fetal blood sampling (FBS). RESULTS: No parameter emerged as a reliable predictor of isoimmunization severity in Group 1. In Group 2, no FBS was necessary in one case since the MCA-PSV values obtained during the follow-up were <1.29 MoM. In two cases the first FBS was already indicated after 1 week of follow-up, but five other fetuses were followed for 3-9 weeks before FBS was indicated. All fetuses with MCA-PSV>1.5 MoM prior to intrauterine transfusion (IUT) had severe fetal anemia on FBS. In fetuses with severe anemia on the first FBS, the MCA-PSV values 7 days before the first FBS were <1.29 MoM (four cases), between 1.29 and 1.5 MoM (two cases) and >1.55 MoM (one case). CONCLUSIONS: In the management of Kell isoimmunization invasive procedures may be avoided by implementing MCA-PSV measurements. Delineation of appropriate intervals between reassessments, the reliability of MCA-PSV following repeated IUTs, and cut-off values for FBS await further study.

Tailored management of twin reversed arterial perfusion (TRAP) sequence.

OBJECTIVE: To describe our management of pregnancies complicated by twin reversed arterial perfusion (TRAP) sequence. METHODS: This was a retrospective study involving all cases of TRAP sequence referred to our fetal medicine unit in a 3-year period (2000-2002). Patients were routinely managed by repeat sonographic surveillance with sonographic anatomical evaluation and detailed echocardiography. Cases with signs of impending cardiac failure were treated by in-utero YAG-laser coagulation of the umbilical vessels of the acardiac twin. RESULTS: Six cases were studied. Three patients in whom there were no signs of deterioration in the status of the pump twin, and in whom the acardiac twin was smaller than the pump twin, were managed conservatively. However, one of these with monoamniotic twins ended in intrauterine fetal death of the pump twin. The other two cases presented with spontaneous cessation of blood flow in the umbilical artery of the acardiac twin. Both delivered at term normal neonates whose follow-up revealed no signs of neurological sequelae. One case of quadruplet pregnancy (with TRAP sequence and two dichorionic twins) was treated by selective termination of the monochorionic twins. Two cases with signs of impending cardiac failure were treated by in-utero YAG-laser occlusion of the vessels in the acardiac mass. Both interventions had a favorable outcome. CONCLUSIONS: Conservative treatment is suitable for milder cases of TRAP sequence in which the pump twin is the larger one. Cases in which the acardiac twin is larger have a poorer prognosis and should be treated by invasive intervention and cord occlusion.

Selective second-trimester termination of an abnormal fetus in twin pregnancies.

The probability of detecting a chromosomal or structural abnormality in one fetus of a dizygotic twin gestation is about twice that of the risk for a singleton. During the period January 1992 to October 1994 we performed selective termination of the abnormal fetus in 14 bichorionic twin gestations. Indications for selective termination were 10 structural abnormalities and 4 chromosomal abnormalities. The procedure was done at 14, 16, and between 20 and 25 weeks in 1, 2, and 11 cases, respectively. We had no pregnancy losses before 24 weeks' gestation. The mean gestational age at delivery was 34.2 +/- 3.9 (SD) weeks. In one case, severe abruptio placentae occurred and the neonate died. Thirteen neonates are alive and well. In five cases in which the procedure was done after 21 weeks' gestation, no decrease in the amount of amniotic fluid in the sac of the terminated fetus was observed. Our experience supports the general conclusion that selective termination for bichorionic abnormal twins is safe and effective.

Pseudo-sinusoidal heart rate associated with major cardiac anomalies.

Pseudo-sinusoidal fetal heart rate (pseudo-SHR) pattern, characterised by intermittent episodes of sinusoidal heart rate and normal fetal heart rate (FHR), is considered benign although its pathophysiologic mechanism remains obscure. We present a case of pseudo-SHR episodes throughout all stages of labor associated with multiple major cardiac anomalies. We suggest that when confronted with repeated episodes of pseudo-SHR pattern, the possibility of an underlying cardiac anomaly should be considered.

Pulpal anesthesia efficacy of four lidocaine solutions injected with an intraligamentary syringe.

Four lidocaine solutions that differed in concentration or vasoconstrictor composition were compared for efficacy of pulpal anesthesia. These drugs were injected in a double-blind manner with the use of an intraligamentary syringe to the periodontal ligament of maxillary lateral incisors. These teeth were subjected to electric pulp test stimulation that yielded absolute sensation threshold values. It was found that there was no dose response relationship between the local anesthetic concentration and the efficacy of pulpal anesthesia. Lidocaine 2% with vasopressin 25 IU% and noradrenaline bitartrate produced a noticeably shorter duration of pulpal anesthesia in comparison with the other three drugs. The results indicated that the nature of vasoconstrictors when added to the local anesthetic can affect the efficacy of pulpal anesthesia using the intraligamentary model.

Postaxial polydactyly. A case report.

Polydactyly is a fairly common congenital foot deformity. Treatment may include simple shoe modification or surgical intervention. Careful preoperative planning must be undertaken with each patient because of the uniqueness of each individual case. A case of type A postaxial polydactyly was presented with a brief review of classification, etiology, and treatment.

Polyadenylated RNA in the lower eukaryote Physarum polycephalum.

Utilizing a method which quantitatively extracts high molecular weight RNA, including intact precursor as well as mature ribosomal RNAs, adenylated molecules have been isolated from nuclear- and cytoplasmic-enriched fractions of Physarum microplasmodia labeled with [3H]-uridine. Electrophoretic analysis of denatured adenylated RNA from the nuclear-enriched fraction indicated the presence of a population of large molecules not found in the cytoplasmic-enriched fraction.

Lens structural disorders in the leopard frog (Rana pipiens) supplied to the laboratory from wild populations.

Examination of lenses of 48 leopard frogs, Rana pipiens, from three commercial suppliers disclosed a high incidence of histologic aberrations. Only four of 17 lenses that appeared totally clear under the dissecting microscope were found to be free of discernible abnormalities on histologic examination. Deviations were most common in the area of elongation. Because of these findings, the applicability of frog lenses for cellular investigations was questioned.

Cellular changes in cultured lenses.

Observations were made on the frog lens epithelium after culture of the entire lens or of capsular explants. General deviations from normal lens structure as well as specific changes in two media were studied. DNA synthesis and mitosis were induced in the central epithelial cells. Disruption of the orderly, single, epithelial layer that is characteristic of normal lenses was accompanied by the appearance of multilayered plaques of epithelial cells and invasion of vacuolated regions of the lens fibers by epithelial cells. Cells that are fibroblast-like in appearance were observed in regions of the capsule depleted of cells and at the free edges of epithelial sheets in cell culture. Epithelial cells were surrounded by capsule-like material even situated in the lens interior. Nuclie derived from central epithelial cells of lenses cultured in L-15 medium and medium 199 had served as donors in previous nuclear transfer experiments in this laboratory. In our current observation of L-15-cultured lenses, cells were sparsely distributed on the capsule and nuclei were abnormally shaped; in 199-cultured lenses, cells were more densely distributed and nuclei resembled those of normal lenses. Medium 199 without serum could better maintain normal lens structure than L-15 medium without serum. In addition, the percentage of epithelial explants demonstrating cellular outgrowth was greater in medium 199. The differences in cellular behavior were shown not to be the result of different sugars, pH, or the presence of CO2. The nuclear transfer results may reflect the structural changes in the epithelium after lens culture in the two media.

Cellular alterations accompany opacification in the cultured lens.

An examination of frog lenses cultured in specific serum-enriched medium was undertaken in order to determine whether such lenses could serve as in vitro models for studying the role of the lens epithelial cell. Histological analysis after sectioning of the lens revealed multilayered epithelial plaques and epithelial invasion of vacuolated cortical fibres, accompanied by the deposition of capsule-like material. A comparison of the effects of two media, L-15 and 199, indicated a greater incidence of opacification induced by L-15, which may be correlated with changes in lens epithelial cell nuclei.