Clinical assessment of amniotic fluid

Maternal and Foetal Outcomes of Newly Diagnosed Chronic Myeloid Leukemia During Pregnancy and its Long-Term Impact

Diagnosing Chronic Myeloid Leukemia (CML) during pregnancy presents challenges for both haematologists and obstetricians. Limited data exists regarding the management of pregnancy-associated CML in low- and middle-income countries (LMICs). This study aimed to assess pregnancy, foetal, and long-term disease outcomes in female patients newly diagnosed with CML in the chronic phase (CML-CP) during pregnancy. A retrospective analysis was conducted on female CML-CP patients presenting between January 2002 and December 2022 at our institution. Inclusion criteria encompassed patients newly diagnosed with CML-CP during pregnancy. Data pertaining to pregnancy outcomes, foetal development, and disease progression were analysed through a comprehensive review of medical records. Among the female CML patients, thirteen were diagnosed with CML-CP during pregnancy. The median patient age was 24 years (range: 20-35). Diagnoses occurred in the first trimester for six patients, the second trimester for three, and the third trimester for four. Outcomes included five elective terminations (38.5%), five pre-term deliveries (38.5%), and three full-term deliveries (23.1%). Management included observation in 6 (46.3%), hydroxyurea in 3 (23.1%), imatinib in 3 (23.1%) and Interferon-α (IFN-α) in 1 (7.7%) patients. Noteworthy obstetric complications encompassed threatened abortion with intrauterine foetal death (IUFD) (1 patient), intrauterine growth retardation (IUGR) (3 patients), oligohydramnios (2 patients), antepartum haemorrhage (1 patient), placental abruption (1 patient), and postpartum haemorrhage (3 patients). At a median follow-up duration of 10.7 years, 11 patients were at a major molecular remission (including 2 patients with deep molecular remission) and two patients progressed to the accelerated phase. The diagnosis and management of CML during pregnancy is a complex and challenging task that requires collaboration between haematologists and obstetricians. Effective management of newly diagnosed CML-CP during pregnancy is contingent on the trimester of presentation. Further research and collaboration are warranted to develop standardised guidelines for managing pregnancy-associated CML, particularly in LMICs.

Does the Summer Season Affect the Amniotic Fluid Volume during Pregnancy?

Amniotic fluid is crucial for the well-being of the fetus. Recent studies suggest that dehydration in a pregnant woman leads to oligohydramnios. We assessed the variation in the amniotic fluid index (AFI) during the summer and non-summer seasons and evaluated neonatal outcomes. We retrospectively reviewed electrical medical records of pregnant women who visited the Konkuk University Medical Center for antenatal care, between July 2005 and July 2019. A total of 19,724 cases from 6438 singleton pregnant women were included after excluding unsuitable cases. All AFI values were classified as 2nd and 3rd trimester values. Additionally, borderline oligohydramnios (AFI, 5–8) and normal AFI (AFI, 8–24) were assessed according to the seasons. The average AFI between the summer and non-summer season was statistically different only in the 3rd trimester; but the results were not clinically significant. In the 3rd trimester, the summer season influenced the increased incidence of borderline oligohydramnios. The borderline oligohydramnios group showed an increased small-for-gestational-age (SGA) rate and NICU admission rate. In the summer season, the incidence of borderline oligohydramnios was seen to increase. This result would be significant for both physicians and pregnant women.

Amniotic fluid index measurements in the second and third trimester and correlation to fetal biometric parameters - new reference based on a big retrospective data

INTRODUCTION

Estimation of amniotic fluid volume (AFV) is part of routine obstetric sonography which reflects maternal-fetal circulation efficiency, fetal hemodynamic status, and a parameter for predicting adverse neonatal outcome. Fetal weight is positively correlated with AFV. Therefore, our objective is to provide a new nomogram of AFV indices and to evaluate the relation between AFV and fetal biometric parameters.

MATERIALS AND METHODS

Retrospective cohort study between 2011 and 2018, at a large tertiary medical center. Data were collected from medical charts of prenatal sonographic evaluation of normal pregnancies, including routine estimation of AFV by using amniotic fluid index (AFI). Generalized estimating equations model was used to study the association between AFI, gestational age and fetal biometric parameters. Centiles were calculated using the Generalized Additive Models for Location, Scale, and Shape model. Box-Cox-t distribution and smoothing splines were used.

RESULTS

Analysis included 28,650 pregnancies. From 25 to 41 weeks gestation, the median and fifth percentile AFI gradually decreased from 174 (IQR 157-193) to 138 mm (IQR 107-173) and from 125 to 68 mm, respectively. The change in the 95th percentile was less significant, ranging around 230 mm throughout pregnancy. Multivariate regression analysis demonstrated a significant correlation between AFI and maternal body mass index (B = -0.147; CI = -0.27 to -0.02), gestational age (B = -11.8; CI = -12.5 to -11.4), estimated fetal weight (EFW) (B = 0.05; CI = 0.049-0.053) and abdominal circumference (AC) (B = 0.94; CI = 0.95-1). There was no correlation between AFI and other fetal biometric parameters.

CONCLUSIONS

We suggest new AFI indices of singleton pregnancies. We found a positive correlation between AFI and EFW and AC.

Isolated oligohydramnios - should induction be offered after 36 weeks?

OBJECTIVE

Isolated oligohydramnios (IO) - oligohydramnios in the absence of maternal or gestational comorbidity is debated as an indication for induction of labor. Previous meta-analyses regarding perinatal outcomes of IO at term have yielded conflicting results. We aimed to investigate the neonatal outcomes among gestations with IO delivered at 36°^/7-39^6/7.

METHODS

The study cohort included all women undergoing a trial of labor between during 2011 and 2019 of a singleton gestation with cephalic presentation between 36°^/7 and 40°^/7. We allocated the study groups into women with IO and those with normal amniotic fluid volume. Neonatal outcomes were compared between the groups and in relation to gestational age and induction of labor.

RESULTS

Overall, there were 529/17,709 (3.0%) IO cases. IO was associated with maternal age <25 years (OR [95% CI] 1.62 (1.20-2.20), p = .001). Induction of labor was more common with IO (OR [95% CI] 1.33 (1.05-1.69) p = .01. IO was associated with preterm delivery (OR [95% CI] 1.81 (1.36-2.40), p < .001). The rate of neonatal adverse outcome did not differ between study groups. Overall composite adverse neonatal outcome occurred among 1,399/17,709 (7.9%) deliveries. Adverse neonatal outcome was associated with induction of labor (OR [95% CI] 1.61 (1.40-1.86), p < .001) and low birth weight (OR [95% CI] 7.41 (6.27-8.75), p < .001). When Stratified by gestational age, neonatal adverse outcome did not differ between IO and no IO groups. When examining cases of induction of labor per gestational age, induction of labor at 36 weeks among IO gestations, was associated with adverse neonatal outcome as compared to no IO group (OR [95% CI] 5.7 (1.23-26.3), p = .04).

CONCLUSIONS

Induction of labor in gestations complicated by IO at 36 weeks gestational age is associated with an increased risk for adverse neonatal outcome. Our study results adds to the current literature regarding outcomes of IO and time of delivery.

SYNOPSIS

Induction of labor in gestations complicated by IO at 36 weeks gestational age is associated with an increased risk for adverse neonatal outcome.

Clinical factors in patients with congenital muscular torticollis treated with surgical resection

BACKGROUND

Congenital muscular torticollis (CMT) is characterized by persistent head tilt toward the affected side. No consensus exists regarding the cause of this disorder. In this study, we analyzed various clinical factors in patients with CMT who were treated with surgical release. This analysis enabled us to identify potential causative factors of CMT and to establish a basis for surgical interventions.

METHODS

In total, 584 patients who underwent surgical intervention for CMT from October 2007 to December 2016 were included in this study. Their demographic characteristics, birthrelated factors, and clinical features were analyzed.

RESULTS

Data from 525 patients were analyzed in this study after exclusion of those with insufficient information. Before birth, 31 patients (5.9%) were diagnosed with oligohydramnios, and 87 (16.6%) had a breech presentation. Seven (1.3%) cases of clavicle fracture and two (0.4%) cases of cephalohematoma were noted at birth. Before surgery, 397 patients (75.6%) underwent physiotherapy and 128 patients (24.4%) did not. The duration of physiotherapy ranged from 1 to 50 months (average, 6 months).

CONCLUSIONS

Our study shows that 16.6% of the CMT patients presented in the breech position, which is a much higher rate than that observed in the general population (3%-4%). We hypothesize that being in the breech position as a fetus appears to exert a significant influence on shortening and fibrosis of the sternocleidomastoid muscle.

Impact of antepartum diagnostic amnioinfusion on targeted ultrasound imaging of pregnancies presenting with severe oligo- and anhydramnios: An analysis of 61 cases

OBJECTIVES

The primary objective our study was to assess the role of diagnostic antepartum amnioinfusion on the yield from targeted ultrasounds performed in pregnancies with severe oligo- and anhydramnios.

STUDY DESIGN

This was a retrospective and descriptive study, conducted in the fetal medicine units of two private tertiary care referral centers in south India. The details of all the cases of diagnostic amnioinfusion performed at these two centers from January 2009 to June 2016 were collected and analyzed. Inclusion criteria were pregnancies between 17 and 26 weeks of gestational age with severe oligo- or anhydramnios. Pregnancies with obvious preterm premature rupture of membranes (PPROM) were excluded. The primary outcome measure was the improvement in diagnostic information pertaining to cause of severe oligo- and anhydramnios, and the nature of such anomalies.

RESULTS

A total of 61 cases of were identified. The median gestational age at performance of the procedure was 22 weeks [IQR, 19.5-23]. The mean volume of normal saline infused was 314±54ml. A significant increase in the single vertical pocket (SVP) was observed following the procedure (pre-procedure SVP=0.6±0.9cm, post procedure SVP=3.4±1.7; paired t test, p<0.001). In 37 cases (37/61, 60.7%), there were no pre-procedure ultrasound findings. There was significant overall detection of abnormalities post procedure (mean pre-procedure findings=0.39±0.49, mean post procedure findings=1.59±1.24; paired t test, p<0.001). The most frequent group of anomalies/abnormalities were renal (36/61, 59%), followed by PPROM (13/61, 21.3%) and finally fetal growth restriction (11/61, 18%).

CONCLUSION(S)

Antepartum amnioinfusion is a valuable ancillary technique in prenatal diagnosis as it increases the diagnostic yield from pregnancies presenting with severe oligo- and anhydramnios.

Isolated Oligohydramnios at Term as an Indication for Labor Induction: A Systematic Review and Meta-Analysis

OBJECTIVE

To investigate whether isolated oligohydramnios at term is associated with increased rates of perinatal morbidity and mortality and whether induction of labor in term pregnancies with isolated oligohydramnios is superior to conservative management in reducing perinatal morbidity and mortality.

STUDY DESIGN

We searched databases from inception to May 2015. We included studies that evaluated isolated oligohydramnios at term and perinatal outcome. Each outcome was analyzed separately, performing a comparative analysis between the study and control groups.

RESULTS

Twelve studies were included with 35,999 women: 2,414 (6.7%) with isolated oligohydramnios and 33,585 (93.29%) with normal amniotic fluid index. Patients with isolated oligohydramnios had significantly higher rates of labor induction [odds ratio (OR) 7.56, confidence interval (CI) 4.58-12.48] and Cesarean sections (OR 2.07, CI 1.77-2.41). There were higher rates of an Apgar score <7 at 1 and 5 min (OR 1.53, CI 1.03-2.26, and OR 2.01, CI 1.3-3.09, respectively) and admission to the neonatal intensive care unit (OR 1.47, CI 1.17-1.84). There were no significant differences in cord pH <7.1 and meconium-stained amniotic fluid. In the single randomized trial comparing induction of labor with expectant management, no differences were found in any significant maternal or neonatal outcomes.

CONCLUSION

Isolated oligohydramnios at term is associated with significantly higher rates of labor induction, Cesarean sections, and short-term neonatal morbidity.

Planned early delivery versus expectant management of the term suspected compromised baby for improving outcomes

BACKGROUND

Fetal compromise in the term pregnancy is suspected when the following clinical indicators are present: intrauterine growth restriction (IUGR), decreased fetal movement (DFM), or when investigations such as cardiotocography (CTG) and ultrasound reveal results inconsistent with standard measurements. Pathological results would necessitate the need for immediate delivery, but the management for 'suspicious' results remains unclear and varies widely across clinical centres. There is clinical uncertainty as to how to best manage women presenting with a suspected term compromised baby in an otherwise healthy pregnancy.

OBJECTIVES

To assess, using the best available evidence, the effects of immediate delivery versus expectant management of the term suspected compromised baby on neonatal, maternal and long-term outcomes.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 May 2015) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials comparing expectant management versus planned early delivery for women with a suspected compromised fetus from 37 weeks' gestation or more.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and assessed trial quality. Two review authors independently extracted data. Data were checked for accuracy. We assessed the quality of the evidence using the GRADE approach.

MAIN RESULTS

Of the 20 reports identified by the search strategy, we included three trials (546 participants: 269 to early delivery and 277 to expectant management), which met our inclusion criteria. Two of the trials compared outcomes in 492 pregnancies with IUGR of the fetus, and one in 54 pregnancies with oligohydramnios. All three trials were of reasonable quality and at low risk of bias. The level of evidence was graded moderate, low or very low, downgrading mostly for imprecision and for some indirectness. Overall, there was no difference in the primary neonatal outcomes of perinatal mortality (no deaths in either group, one trial, 459 women, evidence graded moderate), major neonatal morbidity (risk ratio (RR) 0.15, 95% confidence interval (CI) 0.01 to 2.81, one trial, 459 women, evidence graded low), or neurodevelopmental disability/impairment at two years of age (RR 2.04, 95% CI 0.62 to 6.69,one trial, 459 women, evidence graded low). There was no difference in the risk of necrotising enterocolitis (one trial, 333 infants) or meconium aspiration (one trial, 459 infants), There was also no difference in the reported primary maternal outcomes: maternal mortality (RR 3.07, 95% CI 0.13 to 74.87, one trial, 459 women, evidence graded low), and significant maternal morbidity (RR 0.92, 95% CI 0.38 to 2.22, one trial, 459 women, evidence graded low).The gestational age at birth was on average 10 days earlier in women randomised to early delivery (mean difference (MD) -9.50, 95% CI -10.82 to -8.18, one trial, 459 women) and women in the early delivery group were significantly less likely to have a baby beyond 40 weeks' gestation (RR 0.10, 95% CI 0.01 to 0.67, one trial, 33 women). Significantly more infants in the planned early delivery group were admitted to intermediate care nursery (RR 1.28, 95% CI 1.02 to 1.61, two trials, 491 infants). There was no difference in the risk of respiratory distress syndrome, (one trial, 333 infants), Apgar score less than seven at five minutes (three trials, 546 infants), resuscitation required (one trial, 459 infants), mechanical ventilation (one trial, 337 infants), admission to neonatal intensive care unit (NICU) (RR 0.88, 95% CI 0.35 to 2.23, three trials, 545 infants, evidence graded very low), length of stay in NICU/SCN (one trial, 459 infants), and sepsis (two trials, 366 infants).Babies in the expectant management group were more likely to be < 2.3rd centile for birthweight (RR 0.51, 95% CI 0.36 to 0.73, two trials, 491 infants), however there was no difference in the proportion of babies with birthweight < 10th centile (RR 0.98, 95% CI 0.88 to 1.10). There was no difference in any of the reported maternal secondary outcomes including: caesarean section rates (RR 1.02, 95% CI 0.65 to 1.59, three trials, 546 women, evidence graded low), placental abruption (one trial, 459 women), pre-eclampsia (one trial, 459 women), vaginal birth (three trials 546 women), assisted vaginal birth (three trials 546 women), breastfeeding rates (one trial, 218 women), and number of weeks of breastfeeding after delivery one trial, 124 women). There was an expected increase in induction in the early delivery group (RR 2.05, 95% CI 1.78 to 2.37, one trial, 459 women).No data were reported for the pre-specified secondary neonatal outcomes of the number of days of mechanical ventilation, moderate-severe hypoxic ischaemic encephalopathy or need for therapeutic hypothermia. Likewise, no data were reported for secondary maternal outcomes of postnatal infection, maternal satisfaction or views of care.

AUTHORS' CONCLUSIONS

A policy for planned early delivery versus expectant management for a suspected compromised fetus at term does not demonstrate any differences in major outcomes of perinatal mortality, significant neonatal or maternal morbidity or neurodevelopmental disability. In women randomised to planned early delivery, the gestational age at birth was on average 10 days earlier, women were less likely to have a baby beyond 40 weeks' gestation, they were more likely to be induced and infants were more likely to be admitted to intermediate care nursery. There was also a significant difference in the proportion of babies with a birthweight centile < 2.3rd, however this did not translate into a reduction in morbidity. The review is informed by only one large trial and two smaller trials assessing fetuses with IUGR or oligohydramnios and therefore cannot be generalised to all term pregnancies with suspected fetal compromise. There are other indications for suspecting compromise in a fetus at or near term such as maternal perception of DFM, and ultrasound and/or CTG abnormalities. Future randomised trials need to assess effectiveness of timing of delivery for these indications.

Low amniotic fluid index at term as a predictor of adverse perinatal outcome

AIM

To determine whether an antepartum low amniotic fluid index (AFI) is a predictor of adverse perinatal outcome in normal pregnancy and to determine a threshold level of AFI that could predict an adverse outcome.

METHODS

This was a prospective study conducted among 180 pregnant women at 37-40 weeks of gestation with no known obstetric or medical complications with an AFI ≤ 5th percentile. The results were statistically analyzed and compared.

RESULTS

In the control group, the mean AFI was 10.14 cm and in the study group, it was 4.14 cm. 65 % patients in the study group and 24 % in the control group had a non-reactive non-stress Test. In the control group, 53 % of patients were induced for reasons other than oligohydramnios, while in the study group, 86 % of patients were induced for oligohydramnios. Among the control group, 33 % had a LSCS, while 67 % delivered vaginally; and in the study group, 34 % delivered vaginally and 66 % had a LSCS. In our study, a 5-min APGAR < 7 was seen in 34 % in the study group and 11 % in the control group. 33 % neonates in the control group and 64 % in the study group had birth weights <2.5 kg.

CONCLUSIONS

In the presence of oligohydramnios, perinatal morbidity and mortality are high. Determination of AFI is a valuable screening test for predicting fetal distress.

Amniotic fluid deficiency and congenital abnormalities both influence fluctuating asymmetry in developing limbs of human deceased fetuses

Fluctuating asymmetry (FA), as an indirect measure of developmental instability (DI), has been intensively studied for associations with stress and fitness. Patterns, however, appear heterogeneous and the underlying causes remain largely unknown. One aspect that has received relatively little attention in the literature is the consequence of direct mechanical effects on asymmetries. The crucial prerequisite for FA to reflect DI is that environmental conditions on both sides should be identical. This condition may be violated during early human development if amniotic fluid volume is deficient, as the resulting mechanical pressures may increase asymmetries. Indeed, we showed that limb bones of deceased human fetuses exhibited increased asymmetry, when there was not sufficient amniotic fluid (and, thus, space) in the uterine cavity. As amniotic fluid deficiency is known to cause substantial asymmetries and abnormal limb development, these subtle asymmetries are probably at least in part caused by the mechanical pressures. On the other hand, deficiencies in amniotic fluid volume are known to be associated with other congenital abnormalities that may disturb DI. More specifically, urogenital abnormalities can directly affect/reduce amniotic fluid volume. We disentangled the direct mechanical effects on FA from the indirect effects of urogenital abnormalities, the latter presumably representing DI. We discovered that both factors contributed significantly to the increase in FA. However, the direct mechanical effect of uterine pressure, albeit statistically significant, appeared less important than the effects of urogenital abnormalities, with an effect size only two-third as large. We, thus, conclude that correcting for the relevant direct factors allowed for a representative test of the association between DI and stress, and confirmed that fetuses form a suitable model system to increase our understanding in patterns of FA and symmetry development.

Extrinsic factors influencing fetal deformations and intrauterine growth restriction

The causes of intrauterine growth restriction (IUGR) are multifactorial with both intrinsic and extrinsic influences. While many studies focus on the intrinsic pathological causes, the possible long-term consequences resulting from extrinsic intrauterine physiological constraints merit additional consideration and further investigation. Infants with IUGR can exhibit early symmetric or late asymmetric growth abnormality patterns depending on the fetal stage of development, of which the latter is most common occurring in 70-80% of growth-restricted infants. Deformation is the consequence of extrinsic biomechanical factors interfering with normal growth, functioning, or positioning of the fetus in utero, typically arising during late gestation. Biomechanical forces play a critical role in the normal morphogenesis of most tissues. The magnitude and direction of force impact the form of the developing fetus, with a specific tissue response depending on its pliability and stage of development. Major uterine constraining factors include primigravida, small maternal size, uterine malformation, uterine fibromata, early pelvic engagement of the fetal head, aberrant fetal position, oligohydramnios, and multifetal gestation. Corrective mechanical forces similar to those that gave rise to the deformation to reshape the deformed structures are often used and should take advantage of the rapid postnatal growth to correct form.

Maximal amniotic fluid index as a prognostic factor in pregnancies complicated by polyhydramnios

OBJECTIVES

Polyhydramnios is present in approximately 2% of pregnancies and has been associated with a variety of adverse pregnancy outcomes. Our aim was to evaluate the association between the maximal amniotic fluid index (AFI) and the frequency of specific adverse outcomes.

METHODS

This was a retrospective chart review of 524 singleton pregnancies diagnosed with polyhydramnios and delivered in a single tertiary referral center between 2003 and 2008. Polyhydramnios was defined as either AFI ≥ 25 cm or a maximum vertical pocket (MVP) ≥ 8 cm even in the presence of AFI < 25 cm. The cohort was stratified into four groups based on the maximal AFI noted during the pregnancy: < 25 cm but with MVP ≥ 8 cm; 25-29.9 cm; 30-34.9 cm; and ≥ 35 cm. Data were collected to determine the frequency of the following adverse pregnancy outcomes: prenatally diagnosed congenital anomalies, fetal aneuploidy, preterm delivery, Cesarean delivery, low birth weight, 5-min Apgar score < 7 and perinatal mortality.

RESULTS

Higher AFI was associated with a statistically significant increase in the frequency of adverse pregnancy outcomes. The most severe form of polyhydramnios, as based on the maximal AFI (≥ 35 cm; n = 67), was associated with the highest rates of prenatally diagnosed congenital anomalies (79%), preterm delivery (46%), small-for-gestational-age neonate (16%), aneuploidy (13%) and perinatal mortality (27%). No significant association between degree of polyhydramnios and adverse outcome was demonstrated in cases of idiopathic polyhydramnios (n = 253).

CONCLUSIONS

There is an association between the frequencies of a variety of adverse pregnancy outcomes and the severity of polyhydramnios as reflected by the maximal AFI.

Effect of maternal hydration on the increase of amniotic fluid index

The objective of this study was to determine the effect of maternal hydration with oral isotonic solution and water on the amniotic fluid (AF) index of women with normohydramnios. Women with a normal AF index and gestational age between 33 and 36 weeks without maternal complications were randomized into three groups [isotonic solution (Gatorade(®)), water, control]. The isotonic solution and water groups were instructed to drink 1.5 L of the respective solution and the control group was instructed to drink 200 mL water over a period of 2 to 4 h. AF index was measured before and after hydration by Doppler ultrasonography. The investigator performing the AF index measurement was blind to the subject's group. Ninety-nine women completed the study without any adverse maternal effects. The median increase in AF index after hydration was significantly greater for the isotonic solution and water groups than for the control group. There was no significant difference between the isotonic solution and water groups. Hydration with isotonic solution and water caused a 10-fold (95%CI: 2.09-49.89) and 6-fold (95%CI: 1.16-30.95) increase in the chance of a 20% increase of AF index, respectively. Maternal hydration with isotonic solution or water increased the AF index in women with normohydramnios.

Isolated oligohydramnios in term pregnancy as an indication for induction of labor

OBJECTIVE

To evaluate the outcome of active induction of labor for isolated oligohydramnios in low-risk term gestation.

METHODS

This retrospective study analyzed the obstetric and perinatal outcome of 412 singleton term pregnancies with cephalic presentation and no maternal risk factors or fetal abnormalities. Two groups were compared: 206 deliveries after induced labor for isolated oligohydramnios, and 206 deliveries matched for gestational age following spontaneous labor with normal amniotic fluid index.

RESULTS

The overall rate of cesarean deliveries and cesarean deliveries for nonreassuring fetal status, and operative vaginal delivery rates and those for nonreassuring fetal status were higher in the oligohydramnios group than in the control group. There were no differences between groups in neonatal outcome or perinatal morbidity or mortality.

CONCLUSION

Active induction of labor in term low risk gestations with isolated oligohydramnios translated into higher labor induction, operative vaginal delivery and cesarean section rates. This led to increased maternal risk and an increase in costs with no differences in neonatal outcome.

Proteomic technologies for prenatal diagnostics: advances and challenges ahead

Proteomics-based identification of biomarkers for fetal abnormalities in maternal plasma, amniotic fluid and reproductive fluids has made significant progress in the past 5 years. This is attributed mainly to advances in various technology platforms associated with mass spectrometry-based techniques. As these techniques are highly sensitive and require only small quantities of body fluids, it is hoped that they will pave the way for the development of effective noninvasive approaches, without subjecting the developing fetus to the same degree of harm as current invasive procedures (e.g., amniocentesis). It is possible that these developments will include same-day analyses, thereby permitting rapid intervention when necessary. To date, a host of body fluids, such as maternal serum and plasma, amniotic fluid, cervical fluid, vaginal fluid, urine, saliva or fetal material, such as placental trophoblast, fetal membranes or cord blood, have been used successfully in the quest to develop markers for a number of pregnancy-related pathologies. In the current review update we focus on the emergence of proteomics as a major platform technology in studying various types of fetal conditions and developing markers for pregnancy-related disorders, such fetal aneuploidy, preterm birth, preeclampsia, intra-amniotic infection and fetal stress. Should the development of these markers be successful, then it is to be envisaged that proteomic approaches will become standard of care for a number of disease conditions associated with feto-maternal health.

Prediction of intrapartum Cesarean delivery for non-reassuring fetal status after a successful external cephalic version by a low pre-version pulsatility index of the fetal middle cerebral artery

OBJECTIVE

To determine whether a pre-version Doppler assessment of fetal cerebral and umbilical blood flow can predict the ultimate need for intrapartum Cesarean delivery after a successful external cephalic version (ECV).

METHODS

A prospective observational study on women undergoing ECV between 36 and 38 gestational weeks was performed over a 5-year period. The pulsatility index (PI) of the fetal middle cerebral artery (MCA) and umbilical artery, heart rate and amniotic fluid index were measured before ECV. Women who had successful ECV were then divided into three groups according to the mode of delivery: (1) vaginal delivery, (2) intrapartum Cesarean delivery for poor progress and (3) intrapartum Cesarean delivery for non-reassuring fetal status. The fetal blood flow parameters were compared between the groups. Potential predictors were further analyzed using receiver-operating characteristics curves.

RESULTS

Of 174 women with successful ECV, 140 (80.5%) had vaginal delivery, 19 (10.9%) required emergency intrapartum Cesarean delivery for non-reassuring fetal status and 15 (8.6%) for poor progress. MCA-PI was significantly lower in the group with non-reassuring fetal status. MCA-PI is predictive of intrapartum Cesarean delivery (area under the curve = 0.68, P = 0.021). The sensitivity and specificity at a cut-off level of 1.4 were 62.5% and 76%, respectively, while at a cut-off level of 1.5 they were 68.8% and 63.5%, respectively.

CONCLUSION

Intrapartum Cesarean delivery for non-reassuring fetal status after successful ECV is associated with a lower pre-version fetal MCA-PI.

Amniotic fluid index measurements in normal pregnancy after 28 gestational weeks

OBJECTIVE

The purpose of this study is to establish a normative scale of amniotic fluid index (AFI) or four-quadrant amniotic fluid index throughout gestation in uncomplicated singleton pregnancies, and to identify the lower and upper limits for each gestational week.

METHOD

A prospective longitudinal study was used. One hundred seventeen uncomplicated singleton pregnancies were examined every 4 weeks between 28 and 42 week's gestation. The uterine cavity was divided into four quadrants. With the use of linear-array, real-time B-scanning, the vertical diameter of the largest pocket in each quadrant was measured. The amniotic fluid index is the sum of these four quadrants.

RESULTS

The amniotic fluid index observations from regression equation curve were stratified in week-specific normative curves. The variation between mean AFI of the total population and the means of the preterm was significantly greater than term pregnancies (P<. 05). The AFI 2.5%, 5%, 10%, 90% 95% and 97.5% limits about the 50th (124 mm) were 68, 81, 90, 135, 144 and 145 mm, respectively, in term gestation. The 5th and 95th percentile serves as lower and upper limits of normal, respectively for 28-42 weeks gestation.

CONCLUSIONS

Gestational age-specific values of AFI were established, determining the significant trends of changes in the amniotic fluid volume with gestation. The normogram may have a clinical benefit to accurate, reliable and semiquantitative diagnosis of oligohydramnios and polyhydramnios.

Fetal Growth and Infant Neurodevelopmental Outcome After Preterm Premature Rupture of Membranes

OBJECTIVE

To evaluate the prognostic values of fetal size before birth and fetal growth during the latency period in patients with preterm premature rupture of the membranes (PROM).

METHODS

A prospective cohort study of 69 singleton pregnancies complicated by prolonged (14 days or more) PROM (24 to 31 weeks of gestation). Measures of fetal size and growth were compared with corresponding expected values from our reference curves. The correlations between deviations from expected measures of fetal size and growth, short-term neonatal complications, and infant neurodevelopmental outcome at 2 years were studied by univariate methods and logistic regression.

RESULTS

The mean gestational ages and standard deviations at membrane rupture and at birth were 27.9 +/- 2.4 and 31.5 +/- 2.1 weeks. At a corrected age of 2 years, of the 65 (94.2%) survivors, 3 infants (4.6%) had cerebral palsy, 13 (20%) had minor neurodevelopmental impairment, and 49 (75.4%) were judged to have had normal development. Compared with surviving infants without a major handicap, the group of infants who died and those with cerebral palsy had lower proportions of expected birth weight (0.766 +/- 0.1 as compared with 0.859 +/- 0.13, P =.029), head (0.869 +/- 0.07 as compared with 0.950 +/- 0.07, P =.05), and abdominal (0.793 +/- 0.04 as compared with 0.888 +/- 0.1, P =.001) circumference growth during latency period. In logistic regression analysis, lower-than-expected ultrasound measures of fetal abdominal circumference before birth (odds ratio 1.09; 95% confidence interval 1.01, 1.18) or of abdominal circumference growth during the latency period (odds ratio 1.1; 95% confidence interval 1.01, 1.2) were significantly associated with an increased likelihood of an infant neurodevelopmental abnormality at 2-year follow-up.

CONCLUSION

In pregnancies complicated by preterm PROM, lower-than-expected measures of fetal size and fetal growth were associated with an increased rate of infant neurodevelopmental outcome at 2-year follow-up.

LEVEL OF EVIDENCE

II-2

Amniotic fluid index in normal pregnancy: an assessment of gestation specific reference values among Indian women

AIM

To obtain a gestational reference range for the amniotic fluid index (AFI) among Indian women.

METHODS

An analysis of AFI estimations was undertaken in 517 Indian women with normal pregnancy between 16 and 42 weeks of gestation. It was a prospective, cross-sectional study conducted in a university teaching hospital. Women with fetal anomalies, pregnancy-induced hypertension, diabetes mellitus, and other maternal complications were excluded from the study. The median, the 5th and the 95th percentile values were calculated for each gestational week and these values were compared with other studies.

RESULTS

The median reached its peak at the 27th week of gestation. We observed approximately 6 cm as the lower limit of normal (5th percentile) and approximately 18 cm (95th percentile) as upper limit of normal AFI at term for our population, whereas in the Caucasian population, the values were approximately 7 cm and approximately 20 cm, respectively. All gestation specific AFI values were lower in the studied population of Indian women compared with other studies on Caucasian population (P < 0.01 for 5th percentile & P < 3.26 x 10(-7) for 95th percentile), but slightly higher than the Chinese population.

CONCLUSION

Amniotic fluid index values differ in different populations. We standardized the reference values for normal AFI in Indian women. We found that they are lower in the population studied compared with reported values in the Caucasian population, but slightly higher than the Chinese population.

Direct prediction of amniotic fluid volume in the third trimester by 3-dimensional measurements of intrauterine pockets: a tool for routine clinical use

OBJECTIVE

To develop an ultrasonographic technique for direct prediction of amniotic fluid volume.

STUDY DESIGN

While women with near-term pregnancies were in the supine position, the intrauterine space was divided into 2 hemispheres and each hemisphere was further subdivided into 3 segments. The maximum distances along the 3 axes of amniotic fluid pocket in each segment were measured, and the volume was calculated as a half-ellipsoid or a crescent-cylinder. A sum of these calculations (prediction of amniotic fluid volume [pAFV]) was made and correlated with amniotic fluid volume measured at delivery (mAFV).

RESULTS

In 714 deliveries, a high correlation coefficient of 0.896 between mAFV (mean +/- SD, 296.5 +/- 199.2 mL; range, 20 to 1480 mL) and pAFV (mean +/- SD, 300.2 +/- 180.8 mL; range, 27 to 1262 mL) was obtained. The regression equation was mAFV = 0.968pAFV + 8.68.

CONCLUSION

The regression equation suggested that pAFV could be a direct predictor of intrauterine amniotic fluid volume in the third trimester.

Clinical utility of amniotic fluid volume assessment

Abnormal amniotic fluid volume is associated with increased maternal risk and perinatal morbidity and mortality. Until the advent of ultrasonography, the invasive nature of amniotic fluid volume assessment limited its clinical utility. Refinements in quantifying the noninvasive sonographic assessment of oligohydramnios and hydramnios have improved the ability of clinicians to identify at-risk pregnancies. This article reviews the available methods of amniotic fluid volume assessment and outlines a comprehensive approach to sonographic screening and monitoring.