[Reconstructive subtotal laryngectomy in the treatment of laryngeal cancer]

Surgical techniques of sub-total reconstructive laryngectomies can often prevent the serious impairment of total laryngectomy without having to relinquish oncological radicality. The aim of the present work has been to report on the experience in this field accrued in the ENT Department of the University of Modena from 1987 to 1992. During this period 54 subtotal laryngectomies were performed. Of these, 13 were crico-hyoido-epiglotto-pexies (C.H.E.P.) and the remaining 41 were crico-hyoido-pexies (C.H.P.). The criteria suggested in the literature was adopted for tumor evaluation, surgical indications and contraindications. All the patients had a follow-up of at least 2 years and 31 of them have had at least 5 years of follow-up. There were 9 deaths: 3 due to intervening illnesses, 2 from second primary tumors and 4 from tumor and/or node recurrences. The overall survival was 83.3% at 2 years and 77.6% at 5 years. Determinate survival (ruling out those who had died because of intervening illnesses) were 88.2% and 80%, respectively. There were 11 neoplastic repetitions of which 2 were of the primary tumor, 2 of the primary tumor plus cervical metastases, and 7 of cervical metastases alone. Recovery surgery was performed in 9 patients, 5 of whom are still alive and disease free. Functional recovery (respiration, deglutition) took place slightly earlier in C.H.E.P. than in C.H.P. but in both cases this could be shortened, particularly by introducing a rehabilitative protocol during the immediate post-operative period. In no case did it prove necessary to perform a total laryngectomy to avoid "ab ingestis" problems and only one patient has a permanent tracheostomy.

Uterine allergy: a cause of preterm birth?

OBJECTIVE

To identify the origin of eosinophils in cases of eosinophil-associated preterm delivery.

METHODS

From an established set of 465 consecutive non-anomalous singleton infants delivered at 22-32 weeks' gestation, we retrieved 161 cases of preterm delivery following spontaneous onset of preterm labor, 78 cases with maternal preeclampsia, 33 cases of abruption, and 193 cases of premature rupture of membranes (PROM). Charts were reviewed, and the placenta, umbilical cord, and membranes were examined histologically. In cases with extravascular eosinophils showing evident gradient toward the amniotic cavity, the origin of the eosinophils (fetal or maternal) was determined by the proximity to fetal or maternal vessels.

RESULTS

Histologic evidence of an eosinophilic gradient toward the amniotic cavity was present only in the fetal (including umbilical cord and chorion) compartments. This eosinophilic gradient was present in 19% (90 of 465) of preterm delivery cases and was significantly more common in cases of PROM (54 of 193, 28%) and preterm labor (34 of 161, 21%) than abruption (two of 33, 6%) and preeclampsia (none of 78) (P < .001). In 84 of 90 cases (93%), the eosinophilic gradient was present along with multiple histologic indicators of acute intrauterine inflammation.

CONCLUSION

An eosinophilic gradient toward the amniotic cavity, present in nearly a fifth of cases of preterm delivery, is probably of fetal origin, making it unlikely that a maternal "allergy-like" mechanism is a cause of preterm delivery.

Clinical significance of fetal intracranial hemorrhage

OBJECTIVE

We reviewed our experience with six consecutive cases of fetal intracranial hemorrhage and the cases published in the English literature in an attempt to devise an original prognostic scoring system for antenatal intracranial hemorrhage.

STUDY DESIGN

The series included the cases of fetal intracranial hemorrhage detected at our institution between 1992 and 1994 by transabdominal ultrasonography. In addition, we performed an English literature search (Medline computer search, National Library of Medicine) of all reported cases of a prenatal diagnosis of intracranial hemorrhage. The prenatal ultrasonographic findings were correlated with the clinical outcome, which was divided into (1) normal outcome or mild neurologic sequelae and (2) poor outcome (severe neurologic impairment and fetal or neonatal death).

RESULTS

Six cases of intracranial hemorrhage were detected in a population of 6641 pregnancies (0.9/1000) at our institution. Parenchymal involvement was present in three cases. Review of the English literature revealed 35 additional cases with prenatal ultrasonographic findings and postnatal follow-up. The total cases (n = 41) were divided into three groups: (1) isolated intraventricular hemorrhage (n = 20), (2) parenchymal hemorrhage (n = 13), and (3) subdural or subarachnoid hemorrhage (n = 8). Overall, poor outcome was present in 68% of cases, including 45% (9/20) of intraventricular hemorrhage, 92% (12/13) of parenchymal hemorrhage, and 88% (7/8) of subdural or subarachnoid hemorrhage. The heterogeneity of the intraventricular hemorrhage group in both severity of antenatal findings and outcome prompted us to devise a prognostic scoring system based on prenatal ultrasonographic lesions, grouping cohorts with similar outcomes. Outcome was favorable in 100% (5/5) of grade 1 intraventricular hemorrhage cases, in 50% (6/12) of grade 2 cases, and in 0% (0/3) of grade 3 cases.

CONCLUSIONS

Fetal intracranial hemorrhage can be classified on the basis of the anatomic location of the intracranial bleeding. The prognosis is poor in nearly 90% of parenchymal and subdural hemorrhages, whereas it is better in the subgroup with intraventricular hemorrhage. The prognostic scoring system we propose for intraventricular hemorrhage may assist the physician in providing patients with prognostic information.

Second-trimester amniotic fluid or maternal serum interleukin-10 levels and small for gestational age neonates

OBJECTIVE

To evaluate if interleukin-10 levels in either early second-trimester amniotic fluid (AF) or maternal serum can be utilized as a predictor of the subsequent occurrence of small for gestational age (SGA) infants after controlling for gestational age at delivery.

METHODS

We identified patients who underwent genetic amniocentesis for standard genetic indications or maternal blood sampling for maternal serum alpha-fetoprotein (MSAFP)/triple screen between January 1992 and February 1995 with available follow-up delivery data. Small for gestational age was defined as birth weight less than the tenth percentile for gestational age. Control patients were matched for gestational age at delivery, maternal age, race, and parity with at least two controls for each study patient. We excluded patients with maternal immune disease, chronic hypertension, diabetes, asthma, congenital heart disease, multiple gestation, and fetuses with structural or chromosomal anomalies. Second-trimester AF and serum samples were assayed for interleukin-10. Potential confounding variables considered were MSAFP level, smoking history, pregnancy-induced hypertension, and neonatal gender. The interleukin-10 levels were normalized using natural log transformation for statistical analysis. Statistical analysis included chi 2, Fisher exact test, and analysis of variance, with P < .05 considered significant. RESULTS. From the AF data base, 18 patients (6%) delivered SGA neonates and were matched with 46 controls. From the maternal serum data base, 13 patients (7%) delivered SGA neonates and were matched with 45 controls. Neither AF nor maternal serum interleukin-10 levels were significantly different in patients subsequently delivering SGA neonates compared with controls (AF: median 21.0 pg/mL. [range 13.8-27.6] versus 17.5 pg/mL. [range 8.9-362.12], P = .18; serum: median 15.7 pg/mL [range 9.9-73.5] versus 18.7 pg/mL [range 9.7-71.7], P = .60, respectively). No significant differences were identified in gestational age at sampling, maternal smoking history, pregnancy-induced hypertension, or elevated MSAFP in patients delivering SGA neonates compared with controls (P > .05 for each). As expected, birth weight was significantly lower in patients delivering SGA neonates compared with controls (P < .001).

CONCLUSION

Second-trimester AF or maternal serum interleukin-10 levels are not predictive of subsequent delivery of SGA infants.

Idiopathic fetal growth restriction: a pathophysiologic approach

Known causes of fetal growth restriction (FGR) can be traced in up to 40 percent of the cases. In the remainder of cases, FGR is idiopathic in origin. Evidence from experimental studies, antenatal findings at Doppler velocimetry of the uterine and umbilical arteries, and placental pathology studies suggests that idiopathic FGR can be divided into three groups: 1) primary abnormality in the uteroplacental perfusion; 2) primary abnormality in the fetoplacental perfusion; and 3) abnormal villous structure at the interface between fetal and maternal circulation. An improved understanding of the pathophysiology of idiopathic FGR is crucial to gain insight into its pathogenesis.

GRO alpha in the fetomaternal and amniotic fluid compartments during pregnancy and parturition

PROBLEM

GRO alpha/MGSA is a new member of the chemokine superfamily CXC(alpha) and is produced by a variety of cells including macrophages, fibroblasts, epithelial, and endothelial cells, and keratinocytes. This chemokine has chemoattractant activity and may participate in neutrophil recruitment and activation during the course of intrauterine infection. This study was conducted to investigate the effect of labor and microbial invasion of the amniotic cavity (MIAC) on amniotic fluid, fetal, and maternal plasma GRO alpha concentrations.

METHOD

A cross-sectional study was designed using parameters that included gestational age, results of amniotic fluid (AF) cultures, and labor status at the time of amniocentesis. Fluid was retrieved by transabdominal amniocentesis. MIAC was defined as a positive amniotic fluid culture for bacteria. Umbilical cord blood was retrieved at the time of delivery. Amniotic fluid, maternal and fetal plasma GRO alpha concentrations were measured with a sensitive and specific ELISA (Quantikine, R&D Systems, Minneapolis, MN).

RESULTS

1) GRO alpha was detectable in amniotic fluid, umbilical cord, and maternal plasma samples; 2) GRO alpha concentrations in amniotic fluid increased with advancing gestational age; 3) Both term and preterm gestations with MIAC were associated with higher amniotic fluid GRO alpha concentrations than those with sterile amniotic fluid, independent of the labor status (term, MIAC, labor: median 2.7 ng/ml, range 1.4-12.7 vs. term, no MIAC, labor: median 2.1 ng/ml, range 0.7-3.4, vs term, no MIAC, no labor: median 1.9 ng/ml, range 1.8-4.2; P < 0.005; preterm: MIAC median 5 ng/ml, range 0.6-47.9 vs. no MIAC: median 2.3 ng/ml, range 0.5-10; P < 0.008); 4) A strong correlation was found between umbilical cord plasma GRO alpha concentrations and neonatal neutrophil count, and between GRO alpha concentrations and white blood cell count in the amniotic fluid (r = 0.67, P < 0.0005 and r = 0.38, P < 0.001, respectively).

CONCLUSION

GRO alpha is a physiologic constituent of amniotic fluid and cord blood. Amniotic fluid GRO alpha concentrations increase with gestational age. Intrauterine infection both preterm and at term is associated with an increase in GRO alpha concentrations of amniotic fluid, suggesting that GRO alpha may play an important role in recruitment of neutrophils into the amniotic cavity.

Doppler velocimetry of the fetal middle cerebral artery in patients with preterm labor and intact membranes

A prospective cohort study was conducted to determine whether preterm labor is associated with changes in the impedance to blood flow of the fetal middle cerebral artery. Doppler velocimetry studies were performed in 194 consecutive patients with preterm labor and intact membranes. Pulsatility indices of the middle cerebral artery and umbilical artery were determined on admission. Results were expressed as ratio of the observed pulsatility index to mean value for gestational age expressed as delta MCA PI and delta UA PI, respectively. The prevalence of preterm delivery (< 37 weeks) and delivery within 24 hours of admission was 55.2% (107/194) and 15.5% (30/194), respectively. Patients with an examination-to-delivery interval within 24 hours had significantly lower mean delta MCA PI than that of patients delivered at > or = 37 weeks and > or = 4 weeks after the examination (P < 0.01). Fetuses with a delta MCA PI at or below 0.88 had a relative risk of 2 (95% confidence interval, 1.32 to 2.9) who were delivered within 24 hours compared to controls (sensitivity 76.7%, specificity 62.8%, positive predictive value 26.7%, negative predictive value 93.5%). Stepwise logistic regression analysis indicated that the relationship between delta MCA PI and examination-to-delivery interval remained statistically significant after correcting for cervical dilatation (P < 0.001). Our data indicate that preterm parturition is associated with a decrease in the impedance to flow in the fetal cerebral circulation.

Intrauterine diagnosis and management of transient myeloproliferative disorder

Transient myeloproliferative disorders can be associated with hydrops in Down syndrome fetuses. No cases of prenatal management of such a condition have been reported in the literature. We report a case of myeloproliferative disorder diagnosed by cordocentesis at 31 weeks in a Down syndrome fetus with pericardial effusion. A pericardiocentesis was performed at the first signs of hydrops and successfully improved fetal cardiac function, allowing for continuation of pregnancy.

Prognostic factors for successful expectant management of ectopic pregnancy

OBJECTIVE

To determine the independent ability of initial hCG titers, trend of hCG titers, and ultrasonographic findings in the prediction of successful expectant management in ectopic pregnancy (EP).

DESIGN

Case-control study.

SETTING

University hospital.

PATIENTS

Sixty-seven patients with EP managed expectantly, 49 of whom (73%) had a spontaneous resolution, whereas 3 (5%) underwent medical treatment, and 15 (22%) eventually underwent surgical treatment.

RESULTS

Univariate analysis showed that the initial hCG titer, the trend in hCG titers between first and second sample, and ultrasonographic visualization of absence of an ectopic gestational sac were significant predictors of a successful expectant management. Using receiver operating characteristic curve analysis, an hCG titer < 1,000 mIU/mL was chosen as the optimal cutoff for this prediction, identifying 88% of women destined to have spontaneous resolution of the EP. Multivariate analysis showed that both initial hCG titer and trend in hCG titers but not ultrasonographic visualization of an ectopic gestational sac were independent predictors of a successful or failed expectant management.

CONCLUSION

Expectant management of EP is successful in the majority of patients with initial hCG titer < 1,000 mIU/mL.

Management strategies for congenital infections

Information on congenital infection is continuously expanding. New diagnostic techniques are making significant contributions to the prenatal diagnosis of several fetal infections. In this review we highlight some of the most recent advances in the diagnosis and management of the most common fetal infections, those caused by cytomegalovirus, human immunodeficiency virus 1, Toxoplasma, varicella-zoster virus, and parvovirus B19.

Increased interleukin-6 concentrations in cervical secretions are associated with preterm delivery

OBJECTIVE

This study sought to determine whether elevated concentrations of interleukin-6 in the cervical and vaginal secretions of patients between 24 and 36 weeks' gestation predicted subsequent preterm delivery and/or identified those preterm deliveries associated with maternal infectious morbidity.

STUDY DESIGN

A cohort study was undertaken with cervical and vaginal samples collected from 161 consenting patients seen at 3- to 4-week intervals between 24 and 36 weeks. Levels of interleukin-6 were measured by immunoassay. Demographic, obstetric, neonatal, and laboratory data were analyzed by Fisher's exact test, Student t test, or Wilcoxon rank sum test, linear and multiple logistic regression, and receiver-operator characteristic curve analysis.

RESULTS

There were 4.2-fold and 3.4-fold increases in maximal cervical and vaginal interleukin-6 concentrations, respectively, among patients with preterm deliveries versus term deliveries. The receiver-operator characteristics curve analysis indicated that a single cervical interleukin-6 value > 250 pg/ml of sample buffer, present between 24 and 36 weeks' gestation, optimally identified patients with subsequent preterm deliveries versus term deliveries (sensitivity 50.0%, 95% confidence interval 33.2% to 66.8%; specificity 85.0%, 95% confidence interval 78.8% to 91.2%; positive predictive value 47.2%, 95% confidence interval 30.9% to 63.5%; negative predictive value 86.4%, 95% confidence interval 80.4% to 92.4%). The optimal vaginal interleukin-6 cutoff value (> 125 pg/ml) proved less sensitive (45.5%, 95% confidence interval 28.5% to 62.4%) but equally specific (86.6%, 95% confidence interval 80.7% to 92.5%). Multiple logistic regression indicated that a cervical interleukin-6 level > 250 pg/ml was an independent predictor of preterm delivery (adjusted odds ratio 4.8, 95% confidence interval 1.7 to 14.3). Cervical interleukin-6 levels did not correlate with cervical change or gestational age at sampling. Among patients delivered preterm there were no differences in the mean white blood cell count on admission or the prevalence of vaginal pathogens, alkaline vaginal pH, chorioamnionitis, or endometritis among patients with cervical interleukin-6 values > 150 or < or = 250 pg/ml.

CONCLUSIONS

Cervical interleukin-6 is a relatively insensitive, although fairly specific discriminator of patients with subsequent preterm deliveries. Among patients delivered preterm, elevated cervical interleukin-6 values are not apparently associated with maternal infectious morbidity.

Do uterine leiomyomas influence pregnancy outcome?

To evaluate the clinical significance of the presence, location, size, and number of uterine leiomyomas in pregnancy, a retrospective cohort study in which pregnancy complications and outcome of pregnant women with uterine myomas was undertaken by routine second trimester ultrasound examination. The case group consisted of 183 consecutive women with uterine myomas detected and followed during the years 1983-1989; the control group was made up of all pregnancies diagnosed and followed at the obstetric clinic during the period 1985-1987. The incidences of preterm delivery (less than 37 weeks), preterm premature rupture of membranes, in utero growth retardation (less than 5th percentile), placental abruptio, placenta previa, postpartum hemorrhage (more than 500 cc), and retained placenta were not significantly increased in the group of women with myomas compared with the general population. However, cesarean sections were more common in women with myomas (23 vs 12%; P < 0.001). Within the group of women with myomas, the incidence of cesarean section was not different in cases with multiple rather than solitary myomas, but it was significantly higher in cases of lower uterine segment compared with fundal myomas (39 vs 18%; P < 0.01) and when the mean diameter of the myoma was greater than 5 cm (35 vs 17%; P = 0.01). Stepwise logistic regression analysis showed that both myoma location and size were independent predictors of the odds of cesarean section.

Fetal membrane rupture is associated with the presence of insulin-like growth factor-binding protein-1 in vaginal secretions

OBJECTIVE

Our purpose was to determine whether detection of insulin-like growth factor-binding protein-1 in vaginal secretions could be used in the diagnosis of fetal membrane rupture.

STUDY DESIGN

Consenting patients (n = 105) with complaints suspicious of membrane rupture between 24 and 42 weeks of gestation who had no evidence of placenta previa were enrolled in the study. The diagnosis of membrane rupture required at least two of the following findings on vaginal examination: pooling of fluid, positive Nitrazine paper (Bristol-Myers Squibb, Cherry Hill, N.J.) test, or microscopic evidence of ferning. A swab of the posterior vaginal fornix was obtained, placed in sample buffer, and analyzed for insulin-like growth factor-binding protein-1 by immunoassay. Data analysis included chi 2 analysis, Student t test, or Mann-Whitney U test and linear regression and receiver operating characteristic curve analysis.

RESULTS

A total of 78 (74.3%) patients met the criteria for membrane rupture. There was a highly significant difference in mean vaginal insulin-like growth factor-binding protein-1 concentrations between patients with and without clinical evidence of membrane rupture (553.6 +/- 731.4 micrograms/L vs 3.0 +/- 7.3 micrograms/L, p = 0.0002). Receiver operating characteristic curve analysis demonstrated that the optimal identification of patients with membrane rupture was achieved with an insulin-like growth factor-binding protein-1 value > 3 micrograms/L (sensitivity 74.4%, 95% confidence interval 64.7% to 84.0%; specificity 92.6%, 95% confidence interval 82.7% to 102.5%; positive predictive value 96.7%, 95% confidence interval 92.1% to 101.2%; negative predictive value 55.6%, 95% confidence interval 41.0% to 70.1%).

CONCLUSIONS

The presence of vaginal insulin-like growth factor-binding protein-1 is highly predictive of membrane rupture, identifying 74.4% of affected patients with a very low false-positive rate.

Low concentrations of vaginal fetal fibronectin as a predictor of deliveries occurring after 41 weeks

OBJECTIVE

This study sought to determine whether low concentrations of fetal fibronectin in the cervical and vaginal secretions of patients at 39 weeks' gestation predicted pregnancies progressing beyond 41 weeks' gestation.

STUDY DESIGN

A retrospective cohort study was undertaken using cervical and vaginal samples collected from 75 consenting patients during the thirty-ninth week of gestation. Levels of fetal fibronectin were measured by immunoassay. Demographic, obstetric, neonatal, and laboratory data were analyzed by Fisher's exact test, Student t test or Wilcoxon's rank-sum test, multiple logistic regression, and receiver-operating characteristic curve analysis.

RESULTS

There was a 35.5-fold increase in vaginal fetal fibronectin concentrations among patients delivered at < 41 weeks compared with those delivered at > or = 41 weeks. The receiver-operating characteristic curve analysis indicated that the optimal fetal fibronectin predictor of prolonged pregnancies was a vaginal fetal fibronectin value < 60 ng/ml present between 39 weeks 0 days and 39 weeks 6 days' gestation (sensitivity 95.7%, 95% confidence interval 87.3% to 100.0%; specificity 44.2%, 95% confidence interval 30.7% to 57.7%; positive and negative predictive values 43.1% [95% confidence interval 29.5% to 56.7%] and 95.8% [95% confidence interval 87.8% to 100.0%], respectively). The relative risk for a prolonged pregnancy resulting from a vaginal fetal fibronectin value < 60 ng/ml was 10.4 (1.5 to 72.4). Among patients with a vaginal fetal fibronectin value > or = 60 ng/ml, 80.8% were delivered within 1 week and 92.3% within 10 days of sampling. In contrast, among patients with vaginal fetal fibronectin value < 60 ng/ml 63.3% remained undelivered after 1 week. After parity and cervical dilation were controlled for, multiple logistic regression demonstrated that a vaginal fetal fibronectin value < 60 ng/ml was a significant independent predictor of pregnancies delivered at > or = 41 weeks (adjusted odds ratio 12.8 [95% confidence interval 1.5 to 107.2]).

CONCLUSIONS

A vaginal fetal fibronectin value > or = 60 ng/ml at 39 weeks' gestation is predictive of delivery within 10 days, whereas values < 60 ng/ml identify 95% of pregnancies progressing past 41 weeks' gestation. This data may allow for the prediction of postdates pregnancies, thus facilitating appropriate obstetric interventions.

Congenital nephrosis in low-risk pregnancies

Congenital nephrosis is an autosomal recessive disorder requiring neonatal renal transplant for survival. The postnatal diagnosis rests upon the electron microscopic evaluation of the epithelial foot processes and basal membrane of the glomeruli. The prenatal diagnosis can be suspected in the presence of a positive family history with an amniotic fluid (AF) alpha-fetoprotein level greater than 5 standard deviations (SD) above the population mean accompanied by a negative AF acetylcholinesterase, absent haemoglobin F, and an unremarkable fetal sonographic examination. We reviewed our series of seven cases of congenital nephrosis fulfilling the above criteria; four cases had negative family histories, and in two cases the diagnosis of congenital nephrosis was further supported by the presence of elevated AF albumin concentrations. We conclude that (1) the prenatal diagnosis of congenital nephrosis is feasible in a low-risk population, and (2) an elevated AF albumin concentration may represent an additional marker for the diagnosis of congenital nephrosis, even though false-negative results have been reported.

Risk factors for pulmonary hypoplasia in second-trimester premature rupture of membranes

OBJECTIVE

Our purpose was to determine the independent contribution of gestational age at rupture of membranes, latency period, and severity of oligohydramnios to the prediction of pulmonary hypoplasia in patients with second-trimester premature rupture of membranes.

STUDY DESIGN

All women with premature rupture of membranes at < 28 weeks diagnosed between January 1982 and December 1990 were managed conservatively with a consistent protocol until intrauterine death or spontaneous or induced delivery. The diagnosis of pulmonary hypoplasia was made by strict pathologic and radiographic criteria.

RESULTS

A total of 63 patients fulfilled the inclusion criteria. Pulmonary hypoplasia was present in 15 cases: two of nine stillborns, 12 of 25 neonatal deaths, and one of 24 survivors. All fetuses with pulmonary hypoplasia had oligohydramnios. Univariate analysis showed that the occurrence of pulmonary hypoplasia was significantly associated with gestational age at premature rupture of membranes (p = 0.002), oligohydramnios during the latency period (p = 0.005), and duration of the latency period (p = 0.02). However, logistic regression analysis showed that only the first two variables were independent predictors of pulmonary hypoplasia.

CONCLUSION

Gestational age at premature rupture of membranes and oligohydramnios are independent predictors of the occurrence of pulmonary hypoplasia.

Natural history of uterine leiomyomas in pregnancy

A prospective study was conducted over a 6 year period to determine the natural history of uterine leiomyomas in pregnancy. All pregnant women with myomas detected during obstetric ultrasonographic examination and with three or more sonographic examinations were included; 134 patients fulfilled the inclusion criteria. Sonograms were obtained at 2 week intervals until 20 weeks of gestation, and monthly thereafter. The following observations were made: (1) the majority of myomas 5 cm or less in average diameter could no longer be seen during pregnancy; (2) the majority of myomas greater than 5 cm in diameter tended to remain stable or decrease in size during pregnancy; and (3) multiple myomas were less likely to disappear than solitary myomas.

Prognostic indicators in the prenatal diagnosis of agenesis of corpus callosum

OBJECTIVE

Our aim was to determine the accuracy of ultrasonography in the prenatal diagnosis of agenesis of the corpus callosum and to establish whether ultrasonography can provide prognostic indicators in cases of agenesis of the corpus callosum.

STUDY DESIGN

Prospective ultrasonographic study of the corpus callosum in all cases during an 8-year period in which fetal cerebral ventriculomegaly was detected.

RESULTS

A total of 14 cases of agenesis of the corpus callosum are reported. In seven cases agencies of the corpus callosum was an isolated finding, and in seven cases it was associated with other abnormalities. Six cases involved mendelian syndromes (3 Lissencephaly syndrome, 2 Aicardi syndrome, and 1 Andermann syndrome), and one case was associated with trisomy 13. In 5 of 14 fetuses, all male, agenesis of the corpus callosum was an isolated benign finding. The corpus callosum could never be visualized before midgestation, but diagnosis of agenesis of the corpus callosum was very accurate after 20 weeks.

CONCLUSION

Prenatal ultrasonographic findings suggestive of agenesis of the corpus callosum should be followed by a careful search for associated anomalies that may indicate genetic syndromes. Isolated agenesis of the corpus callosum is often an isolated, benign finding, particularly in male fetuses. In families at risk for mendelian syndromes associated with agenesis of the corpus callosum, lack of visualization of this structure is suggestive of the diagnosis.

Efficacy and tolerability of brodimoprim in bacterial otitis media in children. Controlled study versus cefaclor

78 pediatric patients affected by acute otitis media were selected and randomized into two balanced groups of treatment: brodimoprim, at the dosage of 200 mg once-a-day on the first day and of 100 mg once-a-day on the following days, and cefaclor at a dosage of 40 mg/Kg/day in three doses. Brodimoprim resulted more efficacious in the reduction of symptoms, especially hypoacusis and tinnitus (p < 0.05 between treatments); tympanometry showed a higher number of normalizations in the brodimoprim group, without significant differences between treatments. Both drugs resulted active against most of isolated bacterial strains. Side effects were reported in 4 patients treated with brodimoprim and in 6 patients in the control group.

The effect of fetal gender on the prediction of Down syndrome by means of maternal serum alpha-fetoprotein and ultrasonographic parameters

OBJECTIVE

Our investigation was designed to use maternal serum alpha-fetoprotein and individual or combinations of ultrasonographic parameters to examine the influence of fetal gender on the prediction of Down syndrome.

STUDY DESIGN

A cohort study of 5114 patients who underwent karyotype analysis between 13 and 22 weeks' gestation was undertaken. Maternal demographic variables, anthropometric indices, and maternal serum alpha-fetoprotein values were assessed. Fetal parameters recorded included gender, biparietal diameter, head circumference, femoral and humeral length, transverse cerebellar diameter, and nuchal fold thickness. The effect of fetal gender on maternal serum alpha-fetoprotein values and ultrasonographic parameters was assessed. Gender-specific differences between fetuses with Down syndrome and euploid fetuses were identified, and the optimal cutoff values of individual and combinations of biometric parameters were determined by receiver operating characteristic curve analysis.

RESULTS

A total of 42 fetuses with Down syndrome were identified. Female fetuses with Down syndrome had significantly lower maternal serum alpha-fetoprotein values than their male counterparts, and maternal serum alpha-fetoprotein screening paradigms resulted in the disproportionate identification of affected female fetuses. A nuchal fold thickness > or = 5 mm was the single best ultrasonographic predictor of Down syndrome independent of fetal gender. Affected male fetuses had significantly smaller mean femoral and humeral lengths than euploid fetuses after adjustment for biparietal diameter, but only the humeral length proved a clinically useful predictor of Down syndrome. Pearson's correlation coefficient confirmed that nuchal fold thickness and humeral length were independent of each other and of maternal age and maternal serum alpha-fetoprotein levels. The optimal ultrasonographic predictor of Down syndrome was the presence of either a nuchal fold thickness > or = 6 mm or a humeral length > 3.5 to 3.7 mm below the expected value. This combination of ultrasonographic findings identified 41.7% of female and 66.7% of male fetuses with Down syndrome.

CONCLUSIONS

Fetal gender affects the prediction of Down syndrome by both maternal serum alpha-fetoprotein and ultrasonographic parameters. Moreover, the ultrasonographic detection of Down syndrome in fetuses is greatly improved by a combination of gender-specific biometric parameters.

The risk of second-trimester amniocentesis in twin gestations: a case-control study

OBJECTIVE

Pregnancy outcomes in patients with twin pregnancy undergoing second-trimester amniocentesis for fetal karyotype assessment were compared in a case-control study with twin pregnancies undergoing routine ultrasonographic studies at similar gestational ages.

STUDY DESIGN

All spontaneous and induced twin gestations that underwent ultrasonographic examination between 14 and 20 weeks were compiled for the period January 1987 through January 1992. Patients having undergone multifetal reduction or chorionic villous sampling and those with fetal anatomic or chromosomal anomalies, discordant growth (> 20%), death, or a monoamniotic sac detected at ultrasonography were excluded.

RESULTS

The mean (+/- SD) maternal age was significantly higher among the 101 cases than among the 108 controls (35.2 +/- 3.5 vs 30.4 +/- 5.3 years, respectively; p < 0.01). No differences were noted in gravidity, parity, number of prior spontaneous losses, or gestational age at ultrasonography between the two groups. The fetal loss rate was similar among cases and controls (seven of 202 [3.5%] vs seven of 216 [3.2%], relative risk 1.07, 95% confidence intervals 0.3 to 3.5). No losses occurred within 3 weeks of the procedure. Gestational age at delivery, birth weight, mean Apgar scores at 1 and 5 minutes, and length of neonatal stay were not significantly different between cases and controls.

CONCLUSIONS

Second-trimester amniocentesis in twin pregnancies is apparently not associated with excess pregnancy loss.

Double-blind; placebo-controlled trial of piperacillin prophylaxis in preterm membrane rupture

OBJECTIVE

We attempted to test whether antibiotic therapy prolongs pregnancy in preterm premature rupture of membranes, because preterm premature rupture of membranes is frequently associated with chorionic-decidual infection.

STUDY DESIGN

Women with preterm premature rupture of membranes and a singleton gestation at 24 to 34 completed weeks were randomized to receive either piperacillin 3 gm or placebo intravenously every 6 hours for 72 hours and were managed conservatively until spontaneous delivery, chorioamnionitis, or fetal distress.

RESULTS

Between January 1987 and January 1992, a total of 75 patients were randomized to receive piperacillin (n = 38) or placebo (n = 37). There were no differences between the piperacillin group and the placebo group in mean gestational age at randomization (30.2 +/- 3 vs 30.3 +/- 2.9 weeks). However, a greater number of patients had pregnancy prolonged beyond 7 days (42.1% vs 10.8% p = 0.005) and the mean latency period was significantly prolonged (11.4 +/- 18.8 vs 6.1 +/- 13.6 days, p = 0.001) in the piperacillin group compared with the control groups.

CONCLUSIONS

Use of intravenous piperacillin for 72 hours in preterm premature rupture of membranes significantly prolongs the latency period between membrane rupture and delivery.

Prenatal diagnosis and significance of fetal infections

Viruses like rubella, cytomegalovirus, varicella-zoster virus and parasites like Toxoplasma gondii can be transmitted from a pregnant woman to her fetus and can affect fetal development. Several factors determine the likelihood of fetal infection and the risk of consequences for the fetus, such as the timing of transmission during gestation or the immunologic status of the mother. No single diagnostic modality can be applied to all infections. Knowledge of the diagnostic methods available is essential for accurate counseling and treatment of affected pregnant women.

Walker-Warburg syndrome: prenatal ultrasound findings

The prenatal sonographic findings in a case of Walker-Warburg syndrome are described. The patient was not at risk for this condition. Ultrasound examination at 34 weeks' gestation revealed hydrocephaly, Dandy-Walker anomaly, and striking ocular abnormalities. From a review of the literature it appears that while intracranial abnormalities can lead to the diagnosis in cases at risk for this syndrome, ocular abnormalities are rather characteristic for this syndrome and they should be searched for in every case of hydrocephaly or encephalocele.

Complications of fetal blood sampling

To examine the incidence and significance of complications related to percutaneous fetal blood sampling, we reviewed all the articles published in the English literature on this procedure. Risks of complications and adverse outcomes depend mainly on the gestational age at the time of the procedure, the operator's experience, and the indication for the procedure. To determine the incidence of fetal losses, we pooled the data from series with > 100 cases. After exclusion of cases where some fetal pathologic condition was present, we determined the incidence of adverse outcomes in a low-risk population. In this population fetal blood sampling performed by an experienced operator carries about a 1.4% risk of fetal loss before 28 weeks' gestation and a 1.4% risk of perinatal death (after 28 weeks).

Is fetal blood sampling associated with increased beta-endorphin release into the fetal circulation?

This study was conducted to determine whether fetal blood sampling during the second trimester is associated with changes in circulating fetal beta-endorphin (BE) concentrations. We measured BE concentrations in 68 paired fetal and maternal blood samples obtained between 18 and 28 weeks' gestation. Patients were divided into a control group (n = 50), if the fetal blood samples were obtained by a single umbilical cord puncture, or multiple insertion group (n = 18), if multiple cord punctures were required to obtain a sample. The mean (+/- SE) fetal BE value for the multiple insertion group was significantly higher than BE levels from the control group (771.2 +/- 79.2 pg/ml versus 107.1 +/- 11.7 pg/ml; p < 0.001]. This elevation did not appear to be related to acidosis, since no differences in fetal umbilical pH were observed between the two groups. Fetal BE levels from the control but not from the multiple insertion group significantly correlated with maternal values (Spearman rank r = 0.59; p < 0.001 vs r = -0.08; p > 0.5). In neither group did fetal BE levels correlate with gestational age. These findings indicate that multiple cord punctures at the time of fetal blood sampling are associated with significant increases in BE release. Furthermore, although a maternal or placental contribution to steady state circulating fetal BE cannot be excluded, it would seem that the fetus itself is the primary source of elevated circulating BE levels following multiple cord punctures.

Prenatal detection of monosomy 21 mosaicism

We report a case of chromosomal mosaicism for monosomy 21 revealed in amniotic fluid cell culture. Ultrasound examination at 19 weeks' gestation showed in utero growth retardation and a complex cardiac malformation. A repeated amniocentesis confirmed the presence of monosomy 21 mosaicism. In view of the sonographically detected fetal abnormalities, termination of pregnancy was elected.

Perinatal infections

Information concerning the most recently discovered infections with perinatal implications is constantly expanding. Hepatitis C virus is responsible for the majority of cases of sporadic and transfusion-related non-A, non-B hepatitis. Its prevalence in the general obstetric population is approximately 2%, but it is much higher in intravenous drug users and recipients of blood transfusions. The risk of vertical transmission is probably small (approximately 4.5%), but mothers coinfected with hepatitis C virus and human immunodeficiency virus type 1 are at higher risk of transmitting infection, possibly as a result of higher levels of viremia. Parvovirus B19 infection can jeopardize the fetus in approximately 9% of cases, leading to profound anemia, followed by hydrops and death. B19 has not been proven to be teratogenic, but survivors have a greater risk of in utero growth retardation. Cytomegalovirus remains the most common cause of congenital infections, and the fetal effects of primary maternal infection during gestation can be devastating. Recurrent infections carry a much lower risk of vertical transmission. Prenatal diagnosis is feasible and reliable. The factors affecting the vertical transmission of human immunodeficiency virus type 1 have been further delineated, and new avenues of research have been opened.

Screening for congenital heart disease with the four-chamber view of the fetal heart

OBJECTIVE

Our objective was to determine the efficacy of the four-chamber view of the fetal heart in routine ultrasonographic examination as a screening tool for congenital heart defects.

STUDY DESIGN

A prospective cohort study compared the detection rate of congenital heart defects among 5336 pregnant women screened with the ultrasonographic four-chamber view of the fetal heart from 1987 through 1989 with that among 3680 patients examined ultrasonographically without the four-chamber view during the 2 preceding years (1985 through 1986). All patients were followed until delivery or termination of pregnancy, and clinical or autopsy confirmation of prenatal findings were obtained on all cases.

RESULTS

The overall incidence of congenital heart diseases was 5.2 per 1000 (47/9016). During the years 1985 through 1986 15 neonates with congenital heart diseases were identified, seven of which were prenatally diagnosed (sensitivity 43%). During the period 1987 through 1989 a four-chamber view of the fetal heart was obtained in 95% of cases; 32 cases of congenital heart disease occurred, 26 of which were diagnosed antenatally (sensitivity 81%; p = 0.01). Two false-positive diagnoses were made during the second time period, giving a specificity of 99.9%.

CONCLUSION

The four-chamber view of the fetal heart is easily obtained, does not significantly increase the duration of a routine ultrasonographic examination, and has an excellent sensitivity for the identification of congenital heart diseases.

Prophylactic and emergent arterial catheterization for selective embolization in obstetric hemorrhage

Treatment of obstetric hemorrhage by the selective embolization of damaged pelvic vessels under fluoroscopy holds promise as an alternative to surgical intervention. Unfortunately, the effectiveness of selective embolization is often compromised by its use in emergent settings following the failure of primary operative approaches. Therefore we compared the efficacy of prophylactic versus emergent catheter placement for selective embolization in nine patients with or at risk for obstetric hemorrhage. In four patients with acute obstetric hemorrhage catheterization and embolization was carried out following the failure of initial medical and surgical approaches. In five patients determined to be at risk for intrapartum hemorrhage based on sonographic findings, catheters were inserted into the hypogastric vessels prior to elective cesarean delivery. Three of these five patients subsequently required selective embolization. In comparison to patients undergoing selective embolization following prophylactic catheter placement, patients in the emergent group all had a coagulopathy at the time of embolization, sustained substantially greater blood loss, and had an increased rate of postpartum complications. Finally, there was a significant reduction in total embolization time and therefore in radiation exposure in patients undergoing prophylactic catheter placement prior to selective embolization. These data support the conclusion that in patients determined to be at risk for intrapartum or postpartum hemorrhage the prophylactic placement of catheters allows for selective embolization in a hemodynamically intact patient with stable coagulation indices, theoretically reducing the risk of maternal morbidity and possibly mortality.

Prenatal management of twin gestation. Experience with a new protocol

We carried out a prospective cohort study to evaluate the usefulness of a specific protocol of prenatal management of twin pregnancy to decrease the incidence of prematurity in the population. The protocol particularly stressed the importance of early recognition of uterine contractile activity and early work leave (from 28 weeks' gestation). The outcome of 39 consecutive twin pregnancies that used the protocol over a five-year period was compared with the outcome of 76 twin pregnancies followed by private practitioners and delivered at our department. The two groups were comparable with respect to maternal age, parity, gestational age at diagnosis, socioeconomic level and educational level. The incidence of preterm delivery was significantly lower in the study group than in the control group. Even more significant was the difference in the incidence of severe prematurity (less than 34 weeks' gestation) between the two groups. The use of a protocol like ours, which does not include prolonged hospitalization, home bed rest or tocolytic treatment, is recommended.

Results of a preventive program for congenital toxoplasmosis

All pregnant women followed during the period 1982-87 were screened for toxoplasmosis, and 35 patients had documented seroconversion or doubtful toxoplasmosis titers. One patient opted for pregnancy termination. The remaining were followed with a protocol that included serial ultrasound examinations and prophylactic antibiotic treatment of the mother and neonate. No fetal abnormalities related to congenital toxoplasmosis were found. All the infants had negative toxoplasmosis test titers at birth; at follow-up only one was found to have developed a subclinical infection, at 2 months of age. Our data suggest that antiparasitic treatment during pregnancy for those at risk for Toxoplasma infection may reduce the transmission rate.

Hepatosplenomegaly as the only prenatal finding in a fetus with pyruvate kinase deficiency anemia

A case of congenital pyruvate kinase deficiency manifested at antenatal ultrasound as isolated hepatosplenomegaly is reported and the differential diagnosis is discussed. An aggressive obstetric management and appropriate neonatal care permitted a favorable neonatal outcome.

Pre-induction cervical ripening with prostaglandin E2 gel: intracervical versus intravaginal route

The aim of our study was to evaluate the best method for cervical ripening before a classical induction with amniotomy and oxytocin. One hundred term pregnant patients who presented an unfavorable cervix and an indication for the induction of labor were assigned randomly to either 0.5 mg prostaglandin (PG) E2 gel intracervically (N = 52) or 3 mg PGE2 gel intravaginally (N = 48). The intravaginal gel had a greater effect on cervical ripening according to a modification of the Bishop score than did intracervical gel, but it had a higher incidence of side effects.

Ureteropelvic junction obstruction in utero and ex utero

Seventy cases of ureteropelvic junction obstruction, bilateral or unilateral, were followed prospectively throughout gestation and postnatally for an average of 2.3 years. Cases of ureteropelvic junction obstruction with a renal pelvis dilated less than 1 cm uniformly did well; those with a pyelectasis more than 2 cm, both bilateral and unilateral, had a favorable outcome in approximately three-quarters. Surprisingly, pelvis dilatation between 1-2 cm had a better outcome if bilateral than if unilateral.

[Pre- and post-operative information for the laryngectomized patient: verification of the validity of a brochure]

For those patients who are candidates for total laryngectomy, therapy is not terminated upon surgery and subsequent speech therapy. Treatment must, instead, take into consideration numerous, important psychological problems which arise upon learning the diagnosis and the need for radical surgery. Therefore, all those who come into contact with the patient during the different phases of disease (i.e. the surgeon, ward nurses, speech therapists) must all be made sensitive to such problems. At times the participation of a psychologist is required. Detailed information on both the temporary and permanent modifications due to surgery and on the possibility of obviating the changed physical status are essential to this "global" therapeutic strategy. The authors have, therefore, prepared an explanatory handbook which briefly analyzes the different problems linked to the total laryngectomy in clear, understandable language. Furthermore, they supply information regarding the new behaviour required after surgery. In order to check how valid this type of instrument is as a graphic support to the irreplaceable information given by the health care workers, a questionnaire was sent to 123 members of the Modena Section of the Laryngectomee Association. This questionnaire dealt with the handbook, the information and advice they gained from it both before and after surgery. Questions also involved what sort of speech therapy they had undergone, whether they had an electronic larynx and, if so, was it used. The judgement given on the brochure by most of those interviewed and on the timeliness of its uses from the preoperative stages on was favorable. This favorable judgment stems from the often insufficient information and psychological support provided patients who have undergone, or who will undergo, a total laryngectomy. Such conclusion is clearly drawn from the responses given to the questionnaire. Moreover, the statements given by some of the laryngectomees (even some who had undergone surgery quite some time ago) indicate that they did not know some of the information and practical advice given. Another fact that emerged from the responses is that the esophageal voice is the means of communication of choice and that the electronic larynx was only used in cases where speech therapy had failed.

First trimester diagnosis of a partial mole with the combined use of ultrasound and chorionic villous sampling

A patient with vaginal bleeding in the first trimester of pregnancy had a serum human chorionic gonadotropin (hCG) titer of 495,132 mlU/ml and an abdominal ultrasound examination revealed an intrauterine gestational sac without a fetal pole. Two and a half weeks later the hCG titer was 385,000 mlU/ml and a fetal pole was visualized. Transabdominal villous sampling was performed because of the suspicion of a partial mole. Histopathologic examination showed hydropic villi and chromosomal studies were consistent with triploidy. The diagnosis of partial mole in the first trimester of pregnancy was made and the pregnancy terminated.

Accuracy of ultrasound in the prenatal diagnosis of spinal anomalies

This study was undertaken to determine the accuracy of sonographic examination in the prenatal diagnosis of neural tube defects. The study population consisted of 237 patients divided into three groups according to the indication for the sonographic examination. The overall sensitivity of sonography in the diagnosis of neural tube defects was 94.7%, and the specificity was 98.3%. A false positive diagnosis of spina bifida occurred in a fetus affected with ventriculomegaly, omphalocele, severe kyphosis and scoliosis. There were three false negative diagnoses of spina bifida.

Fetal intracranial calcifications

In utero sonographic visualization of fetal intracranial calcifications during the second trimester is reported. Its diagnostic process, which included percutaneous umbilical cord blood sampling and fetal paracentesis, is described.

Antenatal diagnosis of partial agenesis of the corpus callosum: a benign cause of ventriculomegaly

Dilation of the posterior horns of the cerebral ventricles may be an early finding of fetal hydrocephalus, but it is also the hallmark of partial agenesis of the corpus callosum. Reported is the first precise prenatal diagnosis of posterior agenesis of the corpus callosum. Accurate diagnosis allows for appropriate obstetric management.

Amniotic band syndrome in monozygotic twins: prenatal diagnosis and pathogenesis

Amniotic band syndrome is a well-described disorder lacking a precise definition or a scientifically validated hypothesis of pathogenesis. The widely accepted "exogenous" theory suggests that early amniotic rupture leads to the formation of pathologic amniotic strands, which then induce nonanatomic fetal abnormalities. This paradigm appears to be challenged by observations that amniotic band syndrome occurs in monozygotic twin gestations. The exclusive development of amniotic band syndrome in monozygotic versus dizygotic twin gestations, the description of early amniotic rupture in one sac of a dizygotic twin gestation without subsequent fetal abnormalities, and the paradoxical observations of discordance in monoamniotic and concordance in diamniotic twin gestations, fail to support an "exogenous" etiology for amniotic band syndrome.

Prenatal findings in a case of spondylocostal dysplasia type I (Jarcho-Levin syndrome)

We report the first prenatal identification using ultrasound of a fetus affected with spondylocostal dysplasia type I, or Jarcho-Levin syndrome, in a patient without a positive family history for this condition. The fetus was initially evaluated because of a low maternal serum alpha-fetoprotein determination. At 23 weeks, we visualized a shortened spine, disorganization of the vertebral bodies, posterior fusion of the ribs, and normal long-bone biometry. Termination of pregnancy was elected. All features identified with ultrasound were confirmed postnatally. The fetus was affected with Jarcho-Levin syndrome, a recessively inherited condition associated with a 25% recurrence rate.