[Prominent ears. Normal distance between the auricular edge and the side of the head]. / Auriculae alatae. Normalafstand mellem aurikelkant og hovedets sideflade.

The desire of the patients or their parents for surgical correction of protruding ears is not always in accord with the degree of deformity. As complications can not only ruin a good result but can make the situation worse, some degree of deformity must be present. In order to achieve some guidance in this evaluation we have measured the maximum distance between the side of the head and the helix border in 102 girls and 81 boys, aged 6-16 years. We found a range of ten to thirty-three. The mean value increased with age, and the distance in males was 2.89 mm greater than that found in females.

Triplet, quadruplet and quintuplet pregnancies. Management and outcome.

The management and outcome of 46 pregnancies, 37 triplets, 7 quadruplets and 2 quintuplets, were analysed. Management of pregnancies, initiated upon diagnosis of multiple pregnancy, included bed rest, beta-mimetic agents, dexamethasone late in the second trimester and selective cerclage. The mean gestational age at labor was 235 days in triplet pregnancies, 241 for quadruplets and 220 days for quintuplets. Fifty-four percent of the deliveries were by cesarean section and the remainder per vaginam. The mean weight of the neonates was 1809 g for the triplets, 1837 g for quadruplets and 1284 g for the quintuplets. The mean overall Apgar score was 8.13, total perinatal mortality 14.8% and 9.4% in cases more than 28 weeks. There was no statistically significant difference in the outcome for triplets born vaginally or by cesarean section. In recent years there has been a pronounced reduction in neonatal mortality, dropping from 17.3% during 1970-78 to 5.9% from 1979 to 1983 (p less than 0.05), probably due to the improved neonatal treatment.

Fetal hydrocephalus associated with maternal neurofibromatosis.

Neurofibromatosis (NF), an autosomal dominant inherited disorder affecting multiple organ systems, is rare among pregnant women. NF in pregnancy has been reported to be complicated by maternal hypertension, fetal intrauterine growth retardation and fetal wastage. A case of pregnancy associated with neurofibromatosis, complicated by pregnancy aggravated chronic hypertension, asymmetric intrauterine growth retardation and fetal hydrocephalus is described. Possible interrelations between those pathologies are discussed.

Amniotic fluid volume response to esophageal occlusion in fetal sheep.

Although ovine and human fetuses swallow considerable volumes of fluid, the impact of absence of fetal swallowing on amniotic fluid volume regulation is unclear. To study the role of fetal swallowing on urine production and amniotic fluid, seven ovine fetuses (126 +/- 1 days) were chronically prepared with fetal bladder and vascular catheters, an esophageal flow probe, an inflatable esophageal cuff, and amniotic fluid catheters. In the five fetuses that underwent esophageal ligation after the control period, fetal swallowing averaged 0.27 ml/min before occlusion. In response to esophageal occlusion, significant increases were noted in fetal plasma arginine vasopressin (6.9 +/- 2.6 to 16.6 +/- 4.4 pg/ml) and urine osmolality (159 +/- 1 to 324 +/- 30 mOsm/kg), whereas urine volume (0.25 ml/min) did not change. Amniotic fluid volume increased nearly threefold after 3 days of esophageal occlusion (582 +/- 180 to 1530 +/- 271 ml). Amniotic fluid volume remained normal (334 to 419 ml) in the one fetus in which the occluder did not inflate. In the one fetus in which the esophagus was occluded at surgery, amniotic fluid volume was increased after the surgical recovery period (1489 ml). These data indicate an important role of fetal swallowing in amniotic fluid homeostasis and the potential interaction of swallowing with fetal urine production.

Fetal breathing movements before oxytocin induction in prolonged pregnancies.

Fetal breathing movements were recorded before elective labor induction in 65 patients with uncomplicated prolonged pregnancies. Breathing activity was observed in 41 patients and was absent in 24. Comparison of these two groups indicated that the induction period was significantly shorter and the oxytocin requirement significantly lower in the group with no fetal breathing movements (mean, 319.3 vs 648.5 minutes and 1133.7 vs 2708.4 mIU, respectively). These findings remained valid regardless of Bishop scores. The data suggest that fetal breathing movements are predictive of the effectiveness of oxytocin induction in prolonged pregnancies.

Fetal rehydration via intraamniotic fluid: contribution of fetal swallowing.

Amniotic fluid volume is regulated by a balance of fetal fluid production and resorption. Although fetal swallowing is believed to be a major site of fluid resorption, additional routes of fluid exchange also may contribute. In our present study, five chronically prepared, water-restricted, pregnant ewes with singleton fetuses (128 +/- 1 d) were rehydrated via an intraamniotic infusion (100 mL/h over 90 min) of 0.075 M saline. In response to the maternal water restriction, significant increases were noted in maternal and fetal plasma osmolalities (306.6 +/- 1.2 to 315.4 +/- 2.4; 300.5 +/- 1.5 to 311.0 +/- 1.6 mosmol/kg, respectively) and arginine vasopressin concentrations (1.9 +/- 0.2 to 22.6 +/- 5.0; 1.5 +/- 0.1 to 8.5 +/- 2.2 pg/mL, respectively). After the intraamniotic infusion, fetal plasma osmolality (311.0 +/- 1.6 to 303.0 +/- 1.2 mosmol/kg) and hematocrit (36.7 +/- 1.9 to 33.8 +/- 1.4%) significantly decreased although there was no change in maternal arterial blood values. Fetal swallowing averaged 0.39 +/- 0.10 mL/min during the basal period and 0.34 +/- 0.17 mL/min at maximum dehydration, and decreased significantly to 0.19 +/- 0.07 mL/min in response to the intraamniotic infusion. These results indicate the rapid absorption of intraamniotic fluid by the dehydrated ovine fetus, despite the suppression of fetal swallowing. The volume swallowed during and after the intraamniotic infusion was insufficient to account for the observed changes in fetal plasma osmolality and hematocrit. Thus, alternative routes of fluid absorption (i.e. intramembranous flow) likely predominate under conditions of increased fetal plasma to amniotic fluid osmotic gradients.

Transient postpartum diabetes insipidus.

Diabetes insipidus may first present before, during, or immediately after pregnancy. The characteristics of two unusual cases of transient postpartum diabetes insipidus are described and discussed.

Fluorescein angiography in hypertensive pregnancies.

A retrospective study in two university hospitals investigating retinal changes in pregnancies complicated by hypertension, seldom revealed retinal vascular changes in pre-eclamptic toxemia. Fluorescein angiography was performed on 16 severe pre-eclamptic toxemias and 14 chronic hypertension pregnancies. Normal caliber retinal vessels and normal filling time, with no subretinal or subepithelium leakage, was found in all pre-eclamptic toxemic patients. Four out of the 14 chronic hypertensive patients showed signs of mild hypertensive retinopathy. A review of the literature on fluorescein angiography in pregnancy showed that vascular changes in pre-eclamptic toxemia are choroidal rather than retinal.

Ovine fetal breathing and swallowing activity in response to plasma glucose changes.

Fetal swallowing activity generally occurs simultaneously with fetal breathing movements (FBM) in sheep. The present study investigated the FBM and swallowing responses to altered fetal plasma glucose. Fetal lambs were chronically prepared with laryngeal, esophageal and diaphragm electromyogram (EMG) wires, an esophageal flow probe and vascular catheters. Beginning at 138 +/- 1 day, FBM and swallowing were monitored during control periods and in response to intravenous glucose infusions (14 mg/kg/min for 120 min) to fetuses of fed and fasted ewes. Glucose infusions to fetuses of fed ewes resulted in significant increases in fetal plasma glucose (21.2 +/- 0.7 to 40.5 +/- 1.9 mg/dl) and time breathing (46.2 +/- 6.3 to 60.0 +/- 9.5 min/2 h). In response to maternal fasting, fetal glucose levels (13.4 +/- 1.0 mg/dl) and time breathing (23.0 +/- 7.2 min/2 h) decreased significantly. Glucose infusion to fetuses of fasted ewes resulted in significant increases in time breathing (50.3 +/- 13.4 min/2 h) and diaphragmatic EMG activity (1,295 +/- 654 to 3,012 +/- 1,182 spikes/2 h). There was no change from basal levels of fetal EMG swallows (83.2 +/- 4.3 swallows/2 h) or esophageal flow (40.8 +/- 7.9 ml/2 h) in response to maternal fasting or fetal glucose infusions.

Maternal ECG recorded by internal monitoring closely mimicking fetal heart rate in a recent fetal death.

A case of intrapartum fetal death in which the maternal heart rate was recorded by internal fetal monitoring is presented. The electrical activity of the maternal heart was transmitted via the fetal body and the recording mimicked a "normal" fetal heart rate (FHR). The patient was referred because of sudden abdominal pain and bleeding; Doppler fetal heart tones were not heard. Because internal monitoring was synchronous with the maternal pulse, ultrasonography was performed and established the diagnosis of fetal demise. Awareness and usage of simple modalities are mandatory for proper diagnosis in such cases.

Maternal dehydration: impact on ovine amniotic fluid volume and composition.

Maternal dehydration consistent with mild water deprivation or moderate exercise results in maternal and fetal plasma hyperosmolality and increased plasma arginine vasopressin (AVP). Previous studies have demonstrated a reduction in fetal urine and lung fluid production in response to maternal dehydration or exogenous fetal AVP. As fetal urine and perhaps lung liquid combine to produce amniotic fluid, maternal dehydration may affect the amniotic fluid volume and/or composition. In the present study, six chronically-prepared pregnant ewes with singleton fetuses (128 +/- 1 day) were water deprived for 54 h to determine the effect on amniotic fluid. Maternal plasma osmolality (306.5 +/- 0.9 to 315.6 +/- 1.9 mOsm/kg) and AVP (1.9 +/- 0.2 to 22.2 +/- 3.2 pg/ml) significantly increased during dehydration. Similarly, fetal plasma osmolality (300.0 +/- 0.9 to 312.7 +/- 1.7 mOsm/kg) and AVP (1.4 +/- 0.1 to 10.4 +/- 2.4 pg/ml) increased in parallel to maternal values. Amniotic fluid osmolality (276.8 +/- 5.7 to 311.6 +/- 6.5 mOsm/kg) and sodium (139.8 +/- 4.8 to 154.0 +/- 5.4 mEq/l) and potassium (9.1 +/- 1.3 to 13.9 +/- 2.4 mEq/l) concentrations increased while a significant (35%) reduction in amniotic fluid volume occurred (871 +/- 106 to 520 +/- 107 ml). These results indicate that maternal dehydration may have marked effects on maternal-fetal-amniotic fluid dynamics, possibly contributing to the development of oligohydramnios.

The predictive value of fetal breathing movement and Bishop score in the diagnosis of "true" preterm labor.

In 70 patients who were between 32 and 36 weeks' gestation and who complained of painful uterine contractions, real-time ultrasonography was performed to establish the presence or absence of fetal breathing. Ten of the 14 women in whom no fetal breathing movement could be detected were delivered of infants within 48 hours, whereas the pregnancies continued for a week or longer in 52 of the 56 patients in whom fetal breathing was present. There was a good correlation between Bishop score and pregnancy outcome. Of the 48 patients with "unfavorable" cervix (Bishop score less than or equal to 3), 45 were delivered of infants after 1 week or more, whereas of 22 patients with a Bishop score of 4 to 6, nine were delivered of infants within 48 hours and ten pregnancies continued for 1 week or more.

Ripening the highly unfavorable cervix with extra-amniotic saline instillation or vaginal prostaglandin E2 application.

Extra-amniotic saline instillation using a 26-gauge Foley catheter and vaginal application of prostaglandin E2 (PGE2) were compared. Among 52 cases treated with extra-amniotic saline instillation, the mean Bishop score increased from 1.7 to 7.8 in a mean of 2.8 hours. In all cases but one, an increase of the Bishop score of three or more points occurred during a 6-hour period. Prostaglandin E2 tablets (3 mg) applied in the posterior vaginal fornix (once or twice) resulted in an increase in the Bishop score of three or more points in 39 of 54 cases during the 12-hour study period. The mean Bishop score in these "successful" ripenings using PGE2 increased from 1.9 to 5.6 points during a mean time of 8.5 hours. No severe side effects were registered in either procedure.

The source of immunoglobulin E in the fetus at term.

A high level of immunoglobulin E (IgE) in cord blood (CB) is well known to be predictive of the development of clinical allergy during early childhood. We have tried to ascertain the source of IgE in cord blood by carrying out a series of measurements of IgE concentrations in arterial and venous CB of newborns and comparing them to IgE concentrations in blood samples from both parents. We found that the concentrations of IgE in arterial and venous CB were almost completely identical in the 131 newborns examined whereas IgD concentrations were significantly higher in arterial than in venous CB. Moderate but significant positive correlations were found between IgE concentrations in maternal blood and CB; paternal blood and CB; and maternal and paternal blood. Our data suggest that CB-IgE is essentially a product of fetal lymphocytes. The positive correlations found between the IgE blood concentrations in the newborns, the mothers and the fathers, is most likely an effect of the amount and nature of the allergenic constituents in the family environment.

Influence of ritodrine on plasma steroids and human placental lactogen levels in third-trimester pregnancies.

The effects of ritodrine, administered by intravenous, intramuscular or per os routes, upon plasma levels of unconjugated estriol, estradiol, progesterone and human placental lactogen (HPL) were investigated in 24 third-trimester pregnancies. Ritodrine administered at a constant rate of 200 micrograms/min for 3 h, injected intramuscularly 8 x 10 mg/day for 5 days or given orally in doses of 6 x 20 mg/day for 10 days resulted in a significant decrease in the steroid hormone concentration and a significant elevation of HPL levels.

Nonimmune hydrops fetalis associated with angioosteohypertrophy (Klippel-Trenaunay) syndrome.

A case of nonimmune hydrops fetalis in association with angioosteohypertrophy (Klippel-Trenaunay) syndrome is reported for the first time.

Perinatal outcome following physicians' strike of 1983.

Organized public medical services were profoundly disturbed during the 4 months of the physicians' strike in 1983. An unknown proportion of patients were referred to private services, but only a minority of them attended the alternative centers. The findings during the strike and the following 6 months were compared with those of the year 1982. The incidence of high-risk cases and of multiple and premature deliveries were unchanged. There was a significant rise (P less than 0.01) in the rate of cesarean sections during the strike, 10.8%, compared with 7.8% in 1982. Also, a significant reduction in instrumental deliveries and labor inductions was observed during the strike and for 4 months afterwards. There was no change in the perinatal mortality (total and corrected) or in Apgar scores. This indicates that good perinatal results were achieved despite drastic disturbances in organized perinatal care.

Sterilization at the time of cesarean section: tubal ligation or hysterectomy?

The operative, postoperative and subsequent course of 86 patients who underwent cesarean hysterectomy (C.H.) during the years 1970-1979 are compared to an equal number of cesarean sections with tubal ligation (C.S.L.). Both groups are similar regarding age, gravidity, parity, number of living children and indications for abdominal delivery. Operative and postpartum complications of both groups were all minor, although significantly (p less than 0.05) more frequent in the C.S.L. group. More patients of the C.H. group required blood transfusions than the C.S.L. group (p less than 0.01). The mean period of hospitalization was similar in both groups. Two pregnancies occurred after tubal sterilization, a failure rate of 1:43. During the follow-up period, 49 surgical gynecological procedures were performed in the C.S.L. group compared to 1 in the C.H. group. Ten patients of the C.S.L. group subsequently underwent abdominal hysterectomy. Hysterectomy is the procedure of choice for permanent sterilization and prevention of many subsequent gynecological problems. Consideration must be given to coexisting gynecological conditions while considering sterilization at elective C.S. and C.H. should be offered to those patients.

PIP: The operative, postoperative, and subsequent course of 89 patients who underwent cesarean hysterectomy (CH) during the period 1970-79 are compared to an equal number of cesarean sections with tubal ligation (CSL). Both groups are similar with regard to age, parity, gravidity, number of living children, and indications for abdominal delivery. Operative and postpartum complications of both groups were all minor, although significantly (p0.05) more frequent in the CSL group. More patients in the CH group required blood transfusions than the CSL group (p0.01). The mean period of hospitalization was similar in both groups. 2 pregnancies occurred after tubal sterilization, a failure rate of 1:43. During the follow-up period, 49 surgical gynecological procedures were performed in the CSL group compared to 1 in the CH group. 10 patients in the CSL group subsequently underwent abdominal hysterectomy. Hysterectomy is the procedure of choice for permanent sterilization and prevention of many subsequent gynecological problems. Consideration must be given to coexisting gynecological conditions while considering sterilization at elective CSL and CH should be offered to those patients.

Prolapse of the cord: reduction of perinatal mortality by bladder instillation and cesarean section.

The fetal outcome in 135 cases of cord prolapse seen during the period 1970-79 was studied. The fetus was alive at diagnosis in 127 cases. In 88 (69.3%) of the cases, the cord prolapsed during the first stage of labor and they were managed by Vago's method of rapid instillation of saline into the bladder to relieve cord pressure during preparation for cesarean section (CS). In the remaining 39 cases, the cord prolapsed during the second stage of labor and the patients were delivered vaginally. The overall perinatal mortality rate was 8.1%. The perinatal mortality rate among cases with a live fetus at diagnosis was 2.4%. In spite of a long diagnosis-delivery interval, no fetal deaths occurred in the 88 cases managed by bladder instillation and CS. Vaginal delivery of footling presentations was associated with a fetal mortality of 18.2%. The infant depression rate was significantly higher in breech vaginal deliveries than in CSs (P less than 0.001). Fetal bradycardia at the time of diagnosis was associated with an increased infant depression rate following vaginal delivery (39%) as compared with CS (10%). The CS rate in this series is the highest and the perinatal mortality among the lowest yet reported.