Progression of Doppler abnormalities in intrauterine growth restriction

OBJECTIVE

To identify the sequence of progression of arterial and venous Doppler abnormalities from the onset of placental insufficiency in intrauterine growth restriction (IUGR).

METHODS

Prospective observational study of singletons with IUGR (abdominal circumference < 5(th) percentile) who underwent serial standardized umbilical artery (UA), middle cerebral artery (MCA), ductus venosus (DV) and umbilical vein (UV) Doppler surveillance. Time intervals between progressive Doppler abnormalities and patterns of deterioration were related to UA Doppler status and gestational age.

RESULTS

Six hundred and sixty-eight longitudinal examinations were performed in 104 fetuses, identifying three patterns of progression: (1) Mild placental dysfunction (n = 34) that remained confined to the UA/MCA. The UA became abnormal at a median of 32 weeks' gestation but the pulsatility index never exceeded 3 SD above normal. Progression took a median of 33 days, requiring delivery at a median of 35 weeks. (2) Progressive placental dysfunction (n = 49). Initially normal UA Doppler PI at 29 weeks' gestation increased beyond 3 SD, progressing to abnormal MCA, absent/reversed UA diastolic flow, abnormal DV, UV pulsations in 9-day intervals requiring delivery by 33 weeks. (3) Severe early-onset placental dysfunction (n = 21). Markedly elevated UA PI established by 27 weeks' gestation was associated with rapid (7-day intervals) progression to abnormal venous Doppler with median delivery at 30.6 weeks. Gestational age at onset, time to delivery and progression intervals were different between patterns (all P < 0.05).

CONCLUSION

The characteristics of cardiovascular manifestations in IUGR are determined by the gestational age at onset and the severity of placental disease. Recognition of these factors is critical for planning fetal surveillance in IUGR.

Congenital heart disease is a feature of severe infantile spinal muscular atrophy

OBJECTIVE

Homozygous deletions/mutations of the SMN1 gene cause infantile spinal muscular atrophy (SMA). The presence of at least one SMN2 gene copy is required for normal embryogenesis. Lack of SMN protein results in degeneration of motor neurons, while extraneuronal manifestations have been regarded as a chance association with SMA. We report on heart defects in the subgroup of congenital SMA type I patients.

METHODS

Data were recruited from 65 unselected SMA I patients whose diagnosis had been confirmed genetically within the first 6 months of age. SMN2 copy numbers were analysed retrospectively and correlated with clinical findings including heart malformations.

RESULTS

Four (6%) patients had one copy of SMN2, 56 (86%) had two and five (8%) had three SMN2 copies. Three out of four (75%) patients with a single SMN2 copy had congenital SMA with haemodynamically relevant atrial or ventricular septal defects.

CONCLUSIONS

Previous case reports of SMA I patients with congenital heart defects did not clarify whether the cardiac malformations were coincidental. Given the respective incidences of congenitally lethal SMA with a single SMN2 copy and of cardiac septal defects in humans, a chance association of both conditions would occur in less than one out of 50 million individuals. Our findings suggest that the SMN protein is relevant for normal cardiogenesis.

Orofaciodigital syndrome Type IV (Mohr-Majewski): early prenatal diagnosis in siblings

We report the sonographic and autopsy findings in two sibling fetuses with autosomal recessive orofaciodigital syndrome (OFDS) Type IV (Mohr-Majewski) diagnosed at 11-13 weeks' gestation. The first-trimester anomaly scan showed a markedly increased nuchal translucency (NT) thickness in both fetuses (4.7 mm and 5.1 mm). Both fetuses had multiple anomalies involving the brain, cranium, heart and skeletal system and their karyotypes were normal. The pregnancies were terminated and the autopsies showed findings consistent with Mohr-Majewski syndrome. These cases show the overlap between OFDS Type II (Mohr) and lethal short-rib-polydactyly syndrome Type II (Majewski) and confirm both the autosomal recessive inheritance of the condition and our ability to diagnose it early in pregnancy using detailed fetal ultrasonography.

Spectrum and outcome of prenatally diagnosed fetal tumors

OBJECTIVE

To describe the spectrum of prenatally diagnosed fetal tumors, and the course and fetal outcome in affected pregnancies.

METHODS

This was a retrospective study in two German tertiary referral centers of 84 fetuses with tumors diagnosed in the prenatal period. The tumors were classified according to their location and histology.

RESULTS

The most common site of origin was the heart (20/84, 23.8%), followed by the face and neck region (19/84, 22.6%) and the abdomen (16/84, 19%). Lymphangiomas (21/84, 25%) and rhabdomyomas (19/84, 22.6%) comprised half of the tumor histology. Less frequently, teratomas (14/84, 16.6%) and hemangiomas (12/84, 14.2%) were seen. Complications included arrhythmia in cases with rhabdomyoma (8/19, 42%) and signs of heart failure in cases with hemangioma (4/12, 33%) and teratoma (4/14, 28.6%). The overall survival rate was 75%. Cases with either a histological diagnosis of teratoma or tumor located in the brain had the worst prognosis.

CONCLUSION

The combination of sonographic features and their location allows reliable prediction of the histological type in the vast majority of fetal tumors. Malignancy, associated malformations and aneuploidy are observed infrequently. Knowledge of the presence of a fetal tumor facilitates close surveillance by a specialized team, which might lead to early recognition of problems and improve perinatal outcome.

Computerized fetal heart rate analysis, Doppler ultrasound and biophysical profile score in the prediction of acid-base status of growth-restricted fetuses

OBJECTIVE

To investigate the performance of non-stress test (NST), computerized fetal heart rate analysis (cCTG), biophysical profile scoring (BPS) and arterial and venous Doppler ultrasound investigation in the prediction of acid-base status in fetal growth restriction.

METHODS

Growth-restricted fetuses, defined by abdominal circumference < 5(th) percentile and umbilical artery (UA) pulsatility index > 95(th) percentile, were tested by NST, cCTG, BPS, and UA, middle cerebral artery (MCA), ductus venosus (DV) and umbilical vein (UV) Doppler investigation. The short-term variation (STV) of the fetal heart rate was calculated using the Oxford Sonicaid 8002 cCTG system. Relationships between antenatal test results and cord artery pH < 7.20 were investigated, using correlation, parametric and non-parametric tests.

RESULTS

Fifty-six of 58 patients (96.6%) received complete assessment of all variables. All were delivered by pre-labor Cesarean section at a median gestational age of 30 + 6 weeks. The UA pulsatility index (PI) was negatively correlated with the cCTG STV (Pearson correlation - 0.29, P < 0.05). The DV PI was negatively correlated with the pH (Pearson correlation - 0.30, P < 0.02). The cCTG mean minute variation and pH were not significantly correlated (Pearson correlation 0.13, P = 0.34). UV pulsations identified the highest proportion of neonates with a low birth pH (9/17, 53%), the highest number of false positives among patients with an abnormal BPS, abnormal DV Doppler and a STV < 3.5 ms, and also stratified false negatives among patients with an equivocal or normal BPS. Abnormal DV Doppler correctly identified false positives among patients with an abnormal BPS. cCTG reduced the rate of an equivocal BPS from 16% to 7.1% when substituted for the traditional NST. Elevated DV Doppler index and umbilical venous pulsations predicted a low pH with 73% sensitivity and 90% specificity (P = 0.008).

CONCLUSION

In fetal growth restriction with placental insufficiency, venous Doppler investigation provides the best prediction of acid-base status. The cCTG performs best when combined with venous Doppler or as a substitute for the traditional NST in the BPS.

The area behind the heart in the four-chamber view and the quest for congenital heart defects

OBJECTIVE

To evaluate the spectrum of fetal cardiac defects associated with abnormal sonographic findings in the area behind the heart (ABTH) in the four-chamber view.

METHODS

This study included a retrospective review of 393 fetuses with congenital heart defects (CHD) detected in 2003-2005 at our tertiary referral center and a prospective evaluation of 4666 fetal echocardiograms, including 220 cases of CHD, performed between January 2006 and February 2007. The retrospective and prospective groups did not differ significantly with respect to cardiac anomalies or abnormal findings in the ABTH, allowing us to combine the 613 fetuses with CHD investigated over a 50-month period.

RESULTS

In the study period, 69 fetuses had abnormalities of the ABTH (75% with major CHD). In 28 fetuses, two equally sized vessels ran behind the heart. Of these, 26 had an interrupted inferior vena cava with azygos continuation and two had total anomalous infracardiac pulmonary venous connection. In 41 fetuses, only one vessel was visualized, but the descending thoracic aorta was positioned contralateral to the cardiac apex. Of these, 29 had levocardia with right descending aorta. All of them had a right aortic arch. The remaining 12 had dextrocardia with left descending aorta.

CONCLUSIONS

The ABTH in the four-chamber view is easy to evaluate and offers important diagnostic markers for fetal CHD. Thus, it might enhance the screening performance of the four-chamber view. Attention must be paid to the number of vessels behind the heart and their laterality.

Reversed end-diastolic flow in the umbilical artery at 10-14 weeks of gestation is associated with absent pulmonary valve syndrome

OBJECTIVE

To determine the incidence of reversed end-diastolic flow (REDF) in the umbilical artery in high-risk first-trimester pregnancies and evaluate associated conditions.

METHODS

This was a prospective evaluation of the umbilical artery Doppler waveforms of 614 consecutive high-risk pregnancies between 10 and 14 weeks of gestation, to determine those with REDF. The associated anomalies and characteristics of these fetuses were then investigated.

RESULTS

In 278/614 (45.3%) fetuses, there was positive end-diastolic flow in the umbilical artery; in 331/614 (53.9%) end-diastolic flow was absent and in 5/614 (0.8%) there was REDF. Three of the five fetuses with REDF had tetralogy of Fallot (TOF) with absent pulmonary valve syndrome (APVS) and a patent ductus arteriosus, and all three showed signs of cardiac failure, with reversed blood flow in the ductus venosus during atrial systole and generalized skin edema. Another fetus had a large ventricular septal defect and the remaining fetus had agenesis of the ductus venosus. Three fetuses had trisomy 18 and one had trisomy 13.

CONCLUSIONS

REDF in the umbilical artery is very rare in early pregnancy and mostly occurs in association with major fetal vascular anomalies and cardiac defects, particularly TOF with APVS and patent arterial duct. We propose that the patency of the arterial duct in TOF with APVS leads to heart failure with subsequent demise early in pregnancy. Therefore, the frequent absence of the arterial duct observed in APVS in later pregnancy is more likely to be a result of early selection than a prerequisite for the development of this lesion as has been proposed previously.

Demonstration of autoantibodies to recombinant human sulphite oxidase in patients with chronic liver disorders and analysis of their clinical relevance

It has been shown previously that sera from patients with cholestatic liver diseases react with sulphite oxidase (SO) prepared from chicken liver. In order to analyse this reactivity and the clinical relevance of anti-SO antibodies in more detail, we produced human recombinant SO. Human recombinant SO (60 kDa) was expressed in Escherichia coli and applied to enzyme-linked immunosorbent assay and Western blot. Sera from patients with autoimmune liver disorders [primary biliary cirrhosis (PBC) n = 96; autoimmune hepatitis (AIH) n = 77; primary sclerosing cholangitis (PSC) n = 39], and from patients with other hepatic (n = 154) and non-hepatic chronic inflammatory disorders (n = 113) were investigated. Highest incidence and activities of IgG-anti-SO antibodies were observed in PSC patients. Nine of 16 untreated (56%) and four of 23 PSC patients treated with ursodeoxycholic acid (UDCA) (17%) were positive. Antibody activity decreased significantly during UDCA treatment. Five per cent of PBC and 9% of AIH patients, but also 15% of patients with alcoholic liver disease, were IgG anti-SO-positive. In patients with viral hepatitis and non-hepatic disorders they could be hardly detected. Anti-SO antibodies are further anti-mitochondrial antibodies in chronic liver diseases. They occur predominantly in PSC, and UDCA treatment seams to decrease antibody activity. Whether these antibodies are primary or secondary phenomena and whether they are related to the aetiology or pathogenesis, at least in a subgroup of patients with chronic liver diseases, has still to be evaluated.

Reaction of foster cows to prevention of suckling from and separation from four calves simultaneously or in two steps

The aim of this study was to investigate if a 2-step method of preventing suckling and cow-calf separation reduces the stress reaction in foster cows compared with a simultaneous separation method. Seven Swedish Holstein and 5 Swedish Red dairy cows were used as foster cows, each having a group of 4 calves. The foster cow-calf group was formed when calves were 1 wk old, and the calves were prevented from suckling at 10 wk of age. In 6 of the cow-calf groups, calves were prevented from suckling by simultaneous separation from the cow (control). In the other 6 groups, calves were fitted with a nose-flap, which prevented them from suckling while they were kept together with the cow for another 2 wk before they were separated (2-step). The behavior of the foster cows was observed at 4 observation periods, 0 to 2, 8.5 to 9.5, 24 to 26, and 72 to 74 h after the calves were prevented from suckling (2-step), after separation (2-step), and after calves were prevented from suckling by simultaneous separation (control). For both treatments, saliva cortisol was sampled once daily for 5 d at wk 10. This was repeated at wk 12 for the 2-step treatment. Heart rate was measured with the behavioral observations. Control foster cows vocalized more (P < 0.001) and walked more (P = 0.005) than the 2-step foster cows after prevention of suckling and after separation from the calves. When control cows were separated from their calves, they more frequently (P < 0.001) held their head out of the pen than was the case with 2-step cows when separated 2 wk after prevention of suckling. The variation in heart rate was larger in the control group compared with 2-step cows at 0 to 2 h after separation/prevention of suckling (P = 0.002). No effect of treatment was found on cortisol concentration. Our conclusion is that separating the 2 events "prevention of suckling" and "separation" reduces the stress experienced by the foster cow at weaning.

Partial amniotic carbon dioxide insufflation (PACI) facilitates fetoscopic interventions in complicated monochorionic twin pregnancies

BACKGROUND

Adequate visualization of the placenta or umbilical cord during fetoscopic procedures in complicated monochorionic twin pregnancies may be difficult because of placental position and spatial constraints, as well as stained amniotic fluid. Partial amniotic carbon dioxide insufflation (PACI) has made it possible to overcome these obstacles in other fetoscopic procedures, but its value has not yet been reported in monochorionic twins.

METHODS

Partial amniotic carbon dioxide insufflation was carried out in five expectant women with complicated monochorionic twin pregnancies between 19 + 6 to 29 + 4 weeks of gestation when adequate fetoscopic visualization of pathological placental surface vessels or the umbilical cord was impossible because of stained or too little amniotic fluid. In four cases, five fetoscopic laser ablations of pathological placental vessels in twin-to-twin transfusion syndrome (TTTS) were performed. In one discordant twin pregnancy with TTTS, PACI was carried out in order to achieve umbilical cord ligation in a recipient with omphalocele and cardiac malformation.

RESULTS

Partial amniotic carbon dioxide insufflation offered superior visualization and did not result in any acute maternal or fetal complications. After fetoscopic laser coagulation, three women delivered one fetus at 27 + 5, two fetuses at 28 + 6, and two fetuses at 35 + 4 weeks of gestation, respectively. One set of twins with TTTS was lost. Following umbilical cord ligation, the surviving twin was delivered at 37 + 2 weeks of gestation.

CONCLUSIONS

Partial amniotic carbon dioxide insufflation may facilitate fetoscopic procedures in complicated monochorionic twin pregnancies when conventional fetoscopic approaches within amniotic fluid meet difficulties. Further studies are required to allow assessment of benefits, risks, and safety margins of the new approach before it can generally be recommended.

Clinical application of grey scale and colour Doppler sonography during abnormal third stage of labour

AIM

The purpose of the study was to investigate whether colour Doppler sonography is helpful in the surveillance of abnormal third stage of labour.

MATERIALS AND METHODS

20 patients were enrolled in the prospective study. Inclusion criteria were third stage of labour > 15 min and/or clinical suspicion of retained placenta. By means of grey scale and colour Doppler sonography the length of distinct phases of third stage of labour and length of visualisation of blood flow between myometrium and placenta were measured. These data were compared with previously published normal values.

RESULTS

The patients were allocated into four groups: 1. Patients with prolonged third stage of labour, but normal vaginal delivery of the placenta (Group 1, 8 cases). 2. Patients with clinically suspected retained placental parts (Group 2, 4 cases). 3. Patients with manual removal of the placenta without confirmation of placenta accreta (Group 3, 4 cases). 4. Patients with manual removal of the placenta with confirmation of placenta accreta (Group 4, 4 cases). A significant longer latent phase was responsible for the prolonged third stage of labour in Group 1 (p < 0.05). Blood flow between myometrium and placenta was significantly longer visible in Group 4 than in the normal cohort (p < 0.0001).

CONCLUSION

Grey scale sonography can help to distinguish between uncomplicated and complicated prolonged third stage of labour. Colour Doppler sonography can detect persistent blood flow between myometrium and placenta during third stage of labour in cases of placenta accreta. In these instances, the patient may benefit from colour Doppler sonography-guided curettage.

First-trimester treatment of fetal anemia secondary to parvovirus B19 infection

Here we report two cases of first-trimester parvovirus B19 (PV-B19) infection that were successfully treated by intrauterine blood transfusion into the umbilical vein. At 13 weeks' gestation both fetuses presented with increased nuchal translucency (NT) and cardiomegaly. In both cases pulsed Doppler ultrasound examination of the fetal middle cerebral artery (MCA) revealed increased peak systolic velocity (PSV), which led to a suspicion of fetal anemia. Maternal PV infection was confirmed by a positive polymerase chain reaction result. Each fetus received a 3-mL intravenous transfusion of packed red blood cells into the umbilical vein, using a 25-G spinal needle. Follow-up ultrasound and Doppler examination demonstrated fetal well-being, decline of the MCA-PSV and resolution of the NT. Case 1 was readmitted at 25 weeks' gestation with severe hydrops fetalis, and both mother and fetus still tested positive for PV-B19 DNA. Three more intrauterine blood transfusions were performed and the fetal hydrops resolved. In Case 2 no additional transfusions were needed. Both babies had a good neonatal outcome and uneventful follow-up. Our findings demonstrate that the MCA-PSV is helpful in establishing the diagnosis of first-trimester fetal anemia. Intravasal transfusion can be attempted as early as the first trimester.

Changing attitudes towards non-invasive aneuploidy screening at advanced maternal age in a German tertiary care center

OBJECTIVE

To evaluate attitudes towards non-invasive aneuploidy screening at advanced maternal age in a German tertiary care centre and to compare the rate of invasive testing over a period of four years.

METHODS

A retrospective analysis of 2657 singleton pregnancies with targeted first and second trimester ultrasound examination at 11-14, 15-18 and 19-23 weeks' gestation.

RESULTS

The number of patients at or beyond 35 years increased by 36 % over this period. Concomitant with an increasing proportion of first trimester examinations (+ 13 %), a decrease in 15-18 weeks' examinations (- 14 %), but no changes regarding the 19-23 weeks' examination were observed. A total of 78 (2.9 %) abnormal karyotypes were found and 92 % (56/61) of the cases with autosomal trisomy had sonographic markers suggestive of foetal aneuploidy. The proportion of diagnosed chromosomal abnormalities at 11-14 weeks increased from 14 % in the first half to 49 % in the second half of the study period (p < 0.01). We observed a significant decrease in the rate of invasive procedures, especially in women reassured by a normal ultrasound examination (54 % versus 37 %, p < 0.01).

CONCLUSION

There is an increasing acceptance of first trimester targeted ultrasound examination with the potential advantage of an earlier diagnosis of foetal aneuploidy. Furthermore, we observed annually increasing numbers of women who used the results of the ultrasound examination to guide their final decision about invasive testing, rather than undergo genetic testing as a primary option.