Feto-maternal haemorrhage associated with genetic amniocentesis: results of a randomized trial

Maternal serum alpha-fetoprotein (AFP) levels were determined before and after genetic amniocentesis (n = 283) or ultrasound scan (n = 268) in a group of women participating in a randomized trial of genetic amniocentesis. Increases in AFP levels were seen significantly more often after amniocentesis than after ultrasound scan (P less than 0.001) and 48 women in the amniocentesis group had increases in AFP (delta AFP) that were larger than the maximum delta AFP (+/- 25 micrograms/l) seen in the ultrasound group. If a delta AFP of greater than 25 micrograms/l represents a feto-maternal haemorrhage (FMH) attributable to amniocentesis, the rate of amniocentesis-induced FMH was 17%. Such FMH was seen significantly more often after transplacental amniocentesis or after amniocentesis performed by less experienced operators. No association was detected between birthweight and FMH attributable to amniocentesis.

Randomised controlled trial of genetic amniocentesis in 4606 low-risk women

Outcome of pregnancy after amniocentesis was studied in a randomised controlled trial of 4606 women, age-range 25-34 years, without known risk of genetic disease. Spontaneous abortion rate was 1.7% in the study group after amniocentesis and 0.7% in the control group after ultrasound (relative risk 2.3). In the study group, increased levels of maternal serum alpha-fetoprotein before amniocentesis, perforation of the placenta during amniocentesis, and withdrawal of discoloured amniotic fluid were associated with an increased risk of spontaneous abortion. In the first six weeks after amniocentesis/ultrasound scan, amniotic fluid leakage occurred more often in the study group but there was no difference in the rate of vaginal bleeding. Frequency of postural malformations in the infants in the two groups was the same. In the study group, respiratory distress syndrome was diagnosed more often (relative risk 2.1) and more babies were treated for pneumonia (relative risk 2.5).

Prenatal diagnosis of omphalocele and gastroschisis by ultrasonography

As the use of ultrasonography has become a routine procedure in the care of pregnant women, fetal congenital malformations have been frequently diagnosed prenatally. During a 4-year period abdominal wall defects (AWD) were diagnosed in 14 cases, five were gastroschises and nine were omphaloceles, seven females and seven males. Concomitant malformations were present in one case of gastroschisis and in five cases of omphalocele. Eleven AWD's were diagnosed in the second trimester and six pregnancies were interrupted. Eight children with AWD were born; two boys with omphalocele and one girl and one boy with gastroschisis are still alive. Alpha-fetoprotein was determined in amniotic fluid in 11 cases and also in maternal serum prior to the amniocentesis in eight cases. Chromosomal investigations were performed in 13 cases, 11 on amniotic fluid cells and two on lymphocytes from a blood sample made postnatally. Two abnormal karyotypes, 47,XX + 18 were found.

A possible prenatal evaluation of renal function by amino acid analysis on fetal urine

Intrauterine treatment of 4 fetuses with urethral obstruction was attempted in the third trimester of pregnancy. The fetuses displayed varying sonographic findings including pyelectasis, caliectasis, hydroureter, bladder dilatation, ascites, hydrops, missing kidneys and oligohydramnios. Ultrasonically guided aspiration from the dilated structures was carried out to relieve pressure on the kidney parenchyme and to collect fluid samples for diagnostic purposes. Amino acid concentrations in the fetal urine showed a pattern similar to plasma in 2 fetuses, a pattern almost like urine in 1 fetus and an intermediate pattern in the 4th fetus. Only the fetus with normal amino acid concentrations in the urine survived: the other 3 died in uremia shortly after birth. In 3 cases cells from the aspirated urine were cultured and used for chromosome analysis. The cell cultures grew fast and karyotyping was possible within 1 week. In 2 fetuses an intrauterine catheter was inserted to drain the kidney permanently into the amniotic cavity. In the first case the catheter was displaced to the fetal abdomen after some days of successful drainage. In the second case the catheter tore the placenta, and the child had to be delivered immediately.

Exclusion of citrullinaemia in the first trimester of pregnancy by direct assay of argininosuccinate synthetase in chorionic villi

Citrullinaemia was presumed to be excluded in a fetus at risk by the direct assay of argininosuccinate synthetase in chorionic villi. The diagnosis was confirmed after amniocentesis by normal argininosuccinate synthetase activity in the cultured amniotic fluid cells and by a normal citrulline concentration in the amniotic fluid. The prediction of a normal fetus was confirmed at term by the birth of a non-citrullinaemic boy.

Maternal-serum-alphafetoprotein screening for fetal malformations in 28 062 pregnancies. A four-year experience from a low-risk area

From 1st March, 1980 and up to 29th February 1984 a multicenter serum alpha-fetoprotein (S-AFP) screening project was carried out for the detection of severe fetal malformations. S-AFP was determined by a radio-immunoassay in 28 062 pregnant women between the 16th and 20th week of gestation. Patients with elevated S-AFP values, e.g. above 95 percentile, were examined further with a second S-AFP and by ultrasound scan. 244 amniocenteses (0.9%) were carried out to detect 62 malformations (21 anencephalies, 14 spina bifidas, 2 encephaloceles, 7 omphaloceles, 5 gastroschises, 4 chromosome abnormalities and 9 other malformations). Fifteen of the 16 cases of spina bifida could not be verified by ultrasound scan, whereas all other malformations except chromosome abnormalities were confirmed by ultrasonography. Two cases of spina bifida and one case of skin-covered encephalocele had normal S-AFP concentrations and were therefore not detected. There were no definitive false-positives, e.g. therapeutic abortion of a normal fetus. Our conclusion is that a nationwide S-AFP screening should be recommended.

Successful ultrasound-guided intravascular transfusion in severe fetal anemia without blood group incompability

A 26-year-old patient with chronic acquired pure red cell aplasia had given birth to two infants, both of which died from fetal hydrops and anemia. In her third pregnancy the fetus was diagnosed as being hydropic and anemic in the 24th gestational week. No blood group incompability could be demonstrated. Because of the low gestational age and presence of fetal ascites, intraperitoneal fetal blood transfusion was considered to be without effect, and three fetal intravascular transfusions were therefore performed in the 24th, 26th and 28th gestational weeks. The infant born in the 30th week, is in good health with a normal blood picture, 6 months later. Hydrops and fetal anemia has never been described as a complication of pregnancy in a patient with pure red cell aplasia and it is the first time that intrauterine intravascular fetal transfusion has been used other than for rhesus indication.

Fetal chromosome analysis: screening for chromosome disease?

The aim of the study was to investigate the rationale of the current indications for fetal chromosome analysis. 5372 women had 5423 amniocentesis performed, this group constituting a consecutive sample at the chromosome laboratory, Rigshospitalet, Copenhagen from March 1973 to September 1980 (Group A + B). Pregnant women 35 years of age, women who previously had a chromosomally abnormal child, families with translocation carriers or other heritable chromosomal disease, families where the father was 50 years or more and women in families with a history of Down's syndrome (group A), were compared to women having amniocentesis, although considered not to have any increased risk of fetal chromosome abnormality (1390 pregnancies, group B). They were also compared with 750 consecutive pregnancies in women 25-34 years of age, in whom all heritable diseases were excluded (group C). The risk of unbalanced chromosome abnormality in group A (women with elevated risk) is significantly higher than in group B + C (women without elevated risk) (relative risk 2.4). Women with a known familial translocation and women 40 years or more have a relative risk of 5.7 of having an unbalanced chromosome abnormality compared with women without elevated risk. Spontaneous abortion rate and prematurity rate did not differ from rates expected without amniocentesis. It is concluded that current indications may be characterized as a mixture of evident high risk factors and factors with only a minor influence on risk. Indications for amniocentesis should therefore be reconsidered. Because it must be considered impractical and ethically wrong to limit amniocentesis to the two mentioned real high risk groups, and illogical to continue to present policy, which is not based on clearcut evidence, the possibility of offering amniocentesis to all who want it, is discussed. Screening for chromosome disease in all pregnancies is not without problems, but may be reasonable in some localities.

Increased risk of abortion after genetic amniocentesis in twin pregnancies

Forty-seven twin pregnancies among 3676 patients who had a genetic amniocentesis between 1973 and 1979, are reported. The detection rate of twins at the time of amniocentesis was 62 per cent. Five (17 per cent) of the 29 women with detected twin pregnancy aborted spontaneously, these are compared with 1 (6 per cent) of 18 women with undetected twin pregnancies and with 3 (3 per cent) of 93 singleton pregnancies, selected as controls as they had amniocentesis performed immediately before and after each of the twin mothers. Two of 9 (22 per cent) twin pregnancies, who had at least two punctures in at least one sac aborted, while 3 of 20 twin pregnancies with one puncture in each sac aborted (15 per cent). One of 18 (6 per cent) twin pregnancies, where only one sac was punctured, because the twin pregnancies were undetected, aborted. Amniocentesis of both sacs in twin pregnancies seems associated with an increased risk of spontaneous abortion. The indications for amniocentesis in twin pregnancies should be critically evaluated.

Haemophilia A and B--two years experience of genetic counselling and prenatal diagnosis

Haemophilia A. Thirty-one pregnant women, obligate or probable carriers of haemophilia A, requested prenatal diagnosis if sex determination showed the foetus to be a male. In 11 of the 31 cases the foetuses were females; in two, the genetic variant of the disease rendered prenatal diagnosis impossible; and in two, the mother aborted spontaneously. From the remaining 16 male foetuses, blood samples were obtained in utero in the 17th to 20th week of gestation. Examination of the samples showed that 11 of the foetuses were unaffected and five affected. Haemophilia B. Three carriers of haemophilia B had male foetuses. Examination of foetal blood obtained in utero showed that these three foetuses were affected. Confirmation. All women with an affected foetus requested termination of pregnancy. In one of the cases of abortion, no blood was obtained for confirmative examination. In the remaining cases, the prenatal prediction was confirmed in the abortus or in the child after birth; three women are still pregnant.

Ultrasound-guided fetal intravenous transfusion for severe rhesus haemolytic disease

Intrauterine, intraperitoneal transfusion is associated with a poor survival rate in fetuses with hydrops and low gestational age. A method of direct fetal intravenous transfusion was used in two fetuses. One fetus with severe rhesus haemolytic disease was given transfusions in the 29th and 30th weeks of gestation, using an ultrasound-guided needle through the hepatic part of the umbilical vein without fetoscopy. In another fetus, an experimental cannulation of the umbilical vein succeeded in the 23rd week of gestation. Ultrasound-guided fetal intravenous transfusion avoids the use of fetoscopy, which has limitations, and may improve the prognosis for rhesus-sensitised fetuses.

45,X karyotype: may the diagnosis be suspected on ultrasonic examination in the second trimester of pregnancy?

We report three cases of Turner's syndrome with cystic hygromata, which were diagnosed by routine ultrasound scanning before amniocentesis in the second trimester of pregnancy. Maternal and amniotic level of alpha-fetoprotein were normal. Karyotyping carried out afterwards showed a 45,X karyotype. Our data indicate, that cystic hygromata in Turner's syndrome may coexist with a normal amniotic fluid AFP, thus questioning the theory of leakage from the hygroma. It remains to be investigated if all cases of Turner's syndrome present a cystic hygroma in utero.

Gentamicin-resistant Staphylococcus aureus strains isolated in Denmark in 1979

In 1979 seven gentamicin (G)-resistant (res.) Staphylococcus aureus strains caused epidemic episodes in eight Danish hospitals. Furthermore, a total of 37 resistant strains were isolated from separate incidents. All the G-res. strains were resistant to kanamycin, sisomicin and tobramycin, five to amikacin and two to cephalothin. None were resistant to netilmicin. Twelve out of the total of 44 strains were multiply-res. (resistant to penicillin, streptomycin and tetracyclines), and 10 of these were also resistant to methicillin (M). All phage groups/complexes were represented, group III by 13, and the 83A complex by seven strains. Multiply-res. strains, resistant to both M and G were all resistant to mercury, but sensitive to arsenate, whereas such strains resistant to either M or G usually have been found resistant to both metals. Twenty-three strains lost resistance to G upon storage, among them only one multiply-res. Loss of resistance did not influence the metal resistance pattern. From one patient only, the various isolates (nine) differed in respect to bacteriological properties. It was concluded, however, that they all were descendants of the same unstable strain. In the majority of the cases treatment with G had preceded isolation of the resistant strain.

In vitro comparison of gentamicin and netilmicin including a regression line for netilmicin

The results of two different in vitro investigations are presented: a comparison between gentamicin and netilmicin and a presentation of a regression line for netilmicin. The first investigation comprises 335 bacterial strains. The method used is a plate dilution technique and the susceptibility of the strains is given as IC50 values, i.e. 50% inhibiting concentrations. The conclusion of the study is that netilmicin offers no advantage over gentamicin. In the second investigation a regression line is presented giving the relation between IC50 values for netilmicin and the size of the inhibition zone, based upon 109 bacterial strains. For the disc diffusion method a 20-hour prediffusion technique is used. The disc content is 15 micrograms netilmicin base. The results are discussed and a grouping as to susceptibility is proposed based on the IC50 values found and the blood level obtained after scheduled dose of netilmicin.

Outcome of pregnancy after amniocentesis for chromosome analysis

A consecutive series of 1177 pregnant women examined by amniocentesis for chromosomal abnormalities delivered 1039 live-born babies weighing over 2500 g and 79 live-born babies weighing under 2500 g. Twenty-six abortions were induced (2.2%)--13 (1.1%) because of chromosomal abnormalities--and 28 women (2.4%) aborted spontaneously; in these cases chromosomes were normal. Analysis of all spontaneous abortions in the series suggested that 0.3-0.7% might have resulted from amniocentesis.

Should the indications for prenatal chromosome analysis be changed?

Amniocentesis for chromosome analysis was performed in 1086 pergnant women, 739 of whom had an increased risk of giving birth to a child with chromosome abnormalities. Such abnormalities were found in almost identical proportions among the fetuses with an increased risk (1.2%) and among those with no increased risk (1.4%). Findings in several other studies seem to confirm that there is no significant difference between the risk groups in the proportion of abnormalities found. This suggests that our current risk groups may not be the right ones, but a much larger study is needed to confirm this.

A new type of inactivation of streptomycin by E. coli

Previously described cases of streptomycin inactivation by R-factor carrying strains of E. coli have not lead to any measurable decrease in antimicrobial potency in the bulk substrate toward the culture. In these cases each cell inactivates only a few molecules. Out of 1,800 strains of E. coli we have isolated five strains which inactivate streptomycin in large amounts giving a final concentration of the inactivation product of 0.25 mg/ml in 36 hours. Unlike all other streptomycin-resistant strains in investigated these five strains were sensitive to butyl-streptomycylamine, a streptomycin derivative acting in the same way as streptomycin. The crude inactivation product has been isolated. Inorganic phosphate is liberated by treatment with alkaline phosphatase resulting in a streptomycin-like compound without any antimicrobial activity.

Prenatal karyotyping of twins by ultrasonically guided amniocentesis

Twins were diagnosed with ultrasound in two women who had been referred because of a higher than normal risk of having malformed children. Amniocentesis was carried out under the guidance of ultrasound and amniotic fluid from both fetuses was removed for diagnostic procedures. Injection of Congo red proved that the amniocentesis needle was not re-entering the same amniotic cavity at repeated puncture. In both mothers the fetuses were found to be of different sexes. Mixture of maternal cells was excluded by means of quinacrine staining, allowing evaluation of chromosome markers.