Accuracy of ultrasound diagnoses in pregnancies complicated by suspected fetal anomalies

Referral of pregnancies complicated by suspected fetal anomalies to level III perinatal centres for further evaluation and management is increasing as use of real-time ultrasound spreads, but the sensitivity and specificity of the prenatal diagnoses made in this population are unknown. We undertook a prospective study that followed pregnancies referred to a designated programme dealing with suspected fetal abnormalities. Follow-up of 257 pregnancies revealed that 282 separate anomalies were accurately diagnosed in 212 cases. Normal anatomy was correctly predicted in 42 cases, 16 per cent of the referred population. False-positive and false-negative rates were 1.5 per cent (4/257) and 2 per cent (1/46), respectively. However, 37 per cent of those infants born with anomalies had additional problems not prenatally detected by ultrasound. These results indicate that prenatal ultrasound diagnoses are remarkably accurate overall but that they may be insensitive to associated anomalies in individual cases.

Adult schizophrenia following prenatal exposure to an influenza epidemic

In the context of a Finnish birth cohort, we tested the hypothesis that viral infection during the latter two thirds of fetal development would increase the risk of adult schizophrenic outcome. Psychiatric hospital diagnoses were recorded for all individuals in greater Helsinki who were fetuses during the 1957 type A2 influenza epidemic. Those exposed to the viral epidemic during their second trimester of fetal development were at elevated risk of being admitted to a psychiatric hospital with a diagnosis of schizophrenia. This was true for both males and females and independently in several psychiatric hospitals. The second-trimester effect was seen in the elevated proportion of schizophrenics among those admitted to a psychiatric hospital and also in higher rates of schizophrenia per 1000 live births in the city of Helsinki. The study has several limitations: (1) We have no direct evidence that the subjects actually suffered a viral infection. (2) The psychiatric data were obtained only for subjects up to the age of 26 years, 56 days. (3) The findings are based on hospital diagnoses. (4) The determination of stage of gestation at time of exposure to the epidemic is based on date of birth. The viral infection might have occurred outside the official epidemic window; the infant may have had a preterm or postterm delivery. These sources of error, however, should not serve to enhance the findings. The observed viral effect is interpreted as being one of many potential perturbations of gestation. We suggest that it is less the type than the timing of the disturbance during fetal neural development that is critical in determining risk for schizophrenia.

Spastic hemiparesis and presumed prenatal embolisation

An infant with clinical evidence of prenatal right subclavian arterial occlusion subsequently developed left hemiparesis with cystic infarction of the territory of the right middle cerebral artery. Perinatal strokes have not been reported with signs of limb ischaemia at birth; this finding may be a warning of possible simultaneous cerebral infarction.

Use of furosemide in pregnancies complicated by oligohydramnios

To differentiate pregnancies complicated by oligohydramnios due to intrauterine growth retardation from those due to renal agenesis, the authors administered furosemide intravenously to eight pregnant women (19-25 weeks gestation) with oligohydramnios. The fetal abdomen was scanned with ultrasound to demonstrate the fetal urinary bladder. In six fetuses, sonography failed to demonstrate the bladder: two fetuses had growth retardation with normal kidneys and bladder, and four had renal anomalies. It is concluded that administration of furosemide to the mother fails to induce diuresis in growth-retarded fetuses of 19-23 weeks gestation and that failure to see the fetal bladder after furosemide administration does not necessarily indicate absent fetal kidneys.

Seasonality, birth complications and schizophrenia in a high risk sample

It has been suggested that viral infections, more prevalent in the winter months, might increase pregnancy and birth complications, which might in turn be responsible for the excess of winter-born patients with schizophrenia. In this study it was found that the rate of schizophrenia among high risk winter-urban births who had suffered a perinatal complication was significantly greater than that for those who had not, thus supporting the hypothesis.

Electroencephalographic study of 137 patients with thalidomide embryopathy

EEG examinations were carried out on 137 patients with thalidomide embryopathy aged between 7 and 22 with a mean age of 17.0. Waking and sleep EEGs were normal in 82 (59.9%), and abnormal in 55 (40.1%). The incidence of abnormal EEG was significantly high in the patients associated with mental retardation, and it increased in proportion to the severity of mental retardation. The most frequent abnormal EEG finding was slowing of the basic activity (35/137; 24.8%). The incidence of slowing was significantly higher in the patients with a sensorineural hearing impairment (26/74; 35.1%) than in those with dysmelia (9/62; 14.5%). Slowing appeared frequently in the patients with various cranial nerve symptoms (30/84; 35.7%). The incidence of slowing was found significantly high in the patients with borderline or subnormal intelligence (8/16; 50.0%), and it correlated with the severity of mental retardation. Many patients (48/84; 57.1%) showed unilateral or asymmetrical neurological symptoms. However, asymmetry or focal abnormality in EEG was shown in only 8 patients. Positive spikes appeared frequently in the patients with gonadal dysplasia. Other somatic symptoms, past medical history and family history were not related to the incidence of abnormal EEGs. Eight patients had had epileptic seizures prior to this examination. Another 2 patients had nocturnal enuresis and showed epileptic EEG abnormalities in this examination. The incidence of epilepsy was significantly higher in the patients we examined than among the general population. It is concluded that ingestion of thalidomide during pregnancy affected not only the morphological development of the limbs of the fetus, but the functions of its central nervous system, causing hearing impairment, other cranial nerve symptoms, mental retardation or epilepsy.

Ethical conflicts between mother and fetus in obstetrics

Conflicts between the interests of mother and fetus can create difficult ethical problems for obstetricians. Several types of problems are discussed, with the aim of identifying major viewpoints and arguments supporting each view. Approaches are defended that involve balancing maternal and fetal interests in individual cases, and factors that might be considered in such balancing are identified.

Does an expanding fetal abdominal mass produce pulmonary hypoplasia?

Fetal pulmonary hypoplasia has been related to multiple factors. In an effort to define which fetuses may benefit from prenatal intervention to prevent or reverse pulmonary hypoplasia, we studied the relative contribution of an enlarging abdominal mass in the fetus. We produced abdominal masses in fetal rabbits at 24 days gestation by two methods. In one group, a small cylindrical chip of Takasen, (a synthetic polymer that expands to 50 times its size in 1 week; Grobeast, Pop Art Co, Cleveland, OH) was inserted into the peritoneal cavity of the fetal rabbit; in another group, the bladder neck was obstructed with a surgical clip. Amniotic fluid volume was restored at the surgical procedure. Sham-operated littermates served as controls. At cesarean delivery on day 30, fetal lung, liver, and body weights were measured, and the abdominal masses were quantitated by volume displacement of the removed mass or bladder. In both groups large abdominal masses of comparable size were produced. Newborns with the synthetic abdominal mass did not have significant pulmonary hypoplasia, but often had a prune belly deformity of the abdominal wall, whereas newborns with bladder obstruction had significant pulmonary hypoplasia. Liver weight was not significantly affected. We conclude that a fetal abdominal mass does not independently produce pulmonary hypoplasia, possibly because the "mass effect" is relieved by distension of the abdominal wall rather than elevation of the diaphragm; the pulmonary hypoplasia that occurs in bladder outlet obstruction is probably due to the associated oligohydramnios rather than the mass effect of the dilated urinary tract; and prenatal decompression of an abdominal mass or dilated urinary tract is not justified to prevent pulmonary hypoplasia in the absence of oligohydramnios.

[Acute hydramnios in the 2d half of pregnancy]

95 patients were prospectively examined from 1982-1986 in a diagnostic programme. These patients showed a clinically and ultrasonically established acute hydramnios during the second half of their pregnancy period. Possible important causes of an acute hydramnios can be confirmed or excluded via on-target sonography; at the same time, a diabetic condition must be excluded and the amniotic fluid must be examined to exclude acute viral or specific bacterial infections. In 8 cases (8%) we found that the mother had diabetes mellitus requiring insulin, the hydramnios being the main pointer towards the metabolic disturbance. Gestation diabetes was confirmed in 23 patients (25%) on the basis of the polyhydramnios. Chromosomal anomalies were seen in 12 eucyeses (13%) and in 2 polycyeses. In 8 pregnancies (8%) we found a pattern of non-immunological hydrops fetalis with pleural effusions and ascites. In three patients (3%) there was an immunological hydrops fetalis with polyserositis within an Rh incompatibility pattern. Severe foetal malformations associated with a normal karyotype were sonographically found in 12 pregnancies--encyeses and twins--(12%). Cardiac disturbances (tachyarrhythmia) resulted in polyhydramnios in 8 cases of eucyesis (8%). Finally, 10 cases only remained unclarified (11%). 14 cases (15%) had twin pregnancy. In this connection we observed on the average an earlier onset of acute hydramnios (27 weeks) compared with the eucyeses (on the average during the 30th week). Timely and adequate treatment may become possible if we know the aetiology of the acute hydramnios, especially in cases of diabetes mellitus and gestation diabetes, as well as in certain foetal malfunctions, such as e.g. pleural effusions and generalised hydrops fetalis and disturbances of cardiac rhythm.(ABSTRACT TRUNCATED AT 250 WORDS)

Does fetal gut obstruction cause hydramnios and growth retardation?

In order to study the effects of impaired fetal intestinal absorption of amniotic fluid, two series of neonates (551 from Liverpool and 172 from Rome) with different types of congenital gut obstruction were divided into two groups and compared. Group A consisted of patients with complete obstruction at or above the proximal jejunum (within 15 cm of the ligament of Treitz). Patients of group B had either incomplete obstruction at group A level or either incomplete or complete obstruction at a lower level. Maternal hydramnios and fetal growth retardation rates were found to be significantly higher in group A than in group B. Maternal hydramnios was associated with an increased prematurity rate (P less than .001). Fetal growth retardation was not related to the presence of additional anomalies. In group A growth retardation was more frequent in babies born after 37 weeks of gestation (P less than .05). No differences were found between the Liverpool and Rome series of patients. These findings suggest that fetal gut function not only contributes to the control of amniotic fluid volume but also, in the final stages of pregnancy, to normal fetal growth. Maternal hydramnios may be the cause of premature delivery of fetuses with upper gut obstructions.

Intellectual outcome in children with fetal hypothyroidism

Eighty children with congenital hypothyroidism detected by newborn screening were grouped for presence of fetal hypothyroidism using skeletal maturity at the time of diagnosis as the index. Forty-five children with bone age less than 36 weeks were assigned to the delayed group; 35 with bone age 37 weeks to term were assigned to the nondelayed group. Although most children with athyrosis were found in the delayed group, the groups did not differ in birth weight, hormone levels, or family background. Assessments of intellectual and behavioral characteristics at 1, 2, 3, 4, and 5 years of age revealed that, although children in the delayed group performed within the normal range, their scores were significantly lower than those of the nondelayed group from age 2 years on. Perceptual-motor, visuospatial, and language areas were most affected. There were no differences in behavior or temperamental characteristics.

Etiologic and preventive aspects of epilepsy in the child--bridging the gap between laboratory and clinic

Four broad categories of basic phenomena are pertinent to developing ways to prevent epilepsy. These include mechanisms of epileptogenesis, ictal initiation and temporary entrainment by the seizure discharge of normally functioning brain, seizure propagation, and control mechanisms that function both to restrain the cascade of epileptic events culminating in a seizure and to arrest the epileptic event and restore the interictal state. In newborns and children, hypoxia-ischemia is a major factor leading to epileptogenesis, and several schemes are proposed to classify, quantify, and prevent hypoxic-ischemic encephalopathy. Control mechanisms must be better understood in order to develop prophylactic recommendations for epilepsy, and an experimental model of "kindling antagonism" may increase our understanding of these. Programs of prevention of seizures in children will evolve only if basic researchers and clinicians work productively together to develop an adequate understanding of factors important in epileptogenesis and antiepileptogenic control mechanisms.

Fetal dystocia

Fetal dystocia is the result of an unfortunate relationship between fetal anatomy and maternal pelvic capacity. Most commonly, arrest of labor progress occurs at a point at which the problem is solved without significant risk to maternal-fetal welfare by abdominal delivery. This article has, in part, focused upon some rare exceptions and on how to anticipate and deal with them as well as possible.

Association of adverse perinatal events with an empty sella turcica in children with growth hormone deficiency

High-resolution computed tomography (HR-CT) of the hypothalamo-pituitary region was performed in 26 consecutive children presenting with growth hormone deficiency (GHD) at one clinic. 58% had an empty sella turcica (ES) and 42% a full sella turcica (FS). There was no difference between the ES and FS groups for mean (+/- 95% confidence limits) presentation age (ES 6.7 (+/- 1.8) years, FS 5.6 (+/- 2.2) years), height standard deviation score (SDS) (ES -3.9 (+/- 0.8), FS -3.3 (+/- 0.5] nor head circumference SDS (ES -1.9 (+/- 1.1), FS -0.7 (+/- 1.1]. There were significant associations between the ES group and a history of adverse perinatal events (p less than 0.001) and multiple pituitary deficiency (p = 0.014). Growth hormone response to an acute growth hormone releasing factor test showed no association with HR-CT diagnosis. Sella turcica volumes were calculated from the HR-CT scans. All sella volumes were small; mean SDS for height was -2.6 (+/- 0.2). There was no difference in sella volume SDS between the ES and FS groups (ES -2.9 (+/- 0.3), FS -2.5 (+/- 0.4]. Adverse perinatal events may cause an ES and GHD by compromising the blood supply to the pituitary gland or infundibulum.

Ureteropelvic junction obstruction in the fetus

Ureteropelvic junction (UPJ) obstruction is being detected with increasing frequency before birth. To clarify the natural history of fetal UPJ obstruction, we reviewed our experience managing 28 fetuses; there were 16 bilateral cases for a total of 44 renal units. None required decompression before birth. We found that fetal bilateral UPJ obstruction is associated with significant morbidity and mortality; resolution of fetal hydronephrosis secondary to UPJ obstruction is rare; antenatal diagnosis of UPJ obstruction improves clinical management by allowing early detection and appropriate treatment of otherwise clinically undetectable disease; oligohydramnios in the mature fetus with bilateral UPJ obstruction is an indication for early delivery and immediate repair; and prenatally diagnosed UPJ obstructions should be repaired as early as possible after birth.

Fetal ventricular pacing for hydrops secondary to complete atrioventricular block

The advent of ultrasound recording has expanded the capabilities for treatment of the fetus in utero. The diagnosis of specific disease processes has allowed for prenatal intervention by new techniques designed to improve fetal survival. The application of ventricular pacing in a hydropic fetus with complete atrioventricular (AV) block is reported. Complete AV block resulted from maternal collagen vascular disease. The application of ventricular pacing was to allow for further in utero development and for reversal of hydrops fetalis after improvement in cardiac output. Despite fetal death 4 hours after placement of the ventricular pacing lead, this procedure when applied earlier in the development of hydrops may allow for fetal survival. Ventricular pacing was accomplished without apparent trauma to mother or fetus and no evidence of fetal injury was seen at necropsy. Therefore, in the fetus who would otherwise die in utero before the point of viability ex utero, fetal ventricular pacing may be a rational alternative to current observation.

Antenatal perforation of Meckel's diverticulum presenting as an inflamed hydrocele

A newborn baby presented with an inflamed left hydrocele, which contained intestinal material. This was due to a Meckel's diverticulum that had perforated or separated from the umbilicus sometime before birth causing sterile meconium peritonitis.

Genetic prenatal aqueductal stenosis with hydrocephalus in rat

A recessive mutation which arose in Wistar albino rats was variably expressed in the homozygous state as prenatal stenosis of the aqueduct with resultant hydrocephalus. The condition was often compatible with survival to adulthood and with successful reproduction. Mildly sparse hair was the constant gene marker. Eye defects and sometimes foot deformities occurred. The first observable ultrastructural alteration was a disruption of the integrity of the neuroepithelial basal lamina in the cephalic neural tube of affected embryos as early as the 11th fetal day (16-24 somite pairs). The hydrocephalic syndrome closely resembled that produced by giving folic acid analogs to, or producing vitamin B12 deficiency in, pregnant rats in the period including the 11th day. Neither vitamin B12 nor folate, nor certain metabolites closely related to their metabolism, prevented the gene's expression. Homozygote mutants mated with homozygote mutants produced 70% hydrocephalic (dome-shaped heads) offspring, but if the mother was heterozygote, there was a "protective" effect and the number of hydrocephalic young was disproportionately smaller.