Amnioinfusion in very early preterm prelabor rupture of membranes (AMIPROM): pregnancy, neonatal and maternal outcomes in a randomized controlled pilot study

OBJECTIVE

To assess short- and long-term outcomes of pregnant women with very early rupture of membranes randomized to serial amnioinfusion or expectant management, and to collect data to inform a larger, more definitive clinical trial.

METHODS

This was a prospective non-blinded randomized controlled trial with randomization stratified for pregnancies in which the membranes ruptured between 16 + 0 and 19 + 6 weeks' gestation and 20 + 0 and 23 + 6 weeks' gestation to minimize the risk of random imbalance in gestational age distribution between randomized groups. Intention-to-treat analysis was used. The study was conducted in four UK hospital-based fetal medicine units (Liverpool Women's NHS Trust, St Mary's Hospital Manchester, Birmingham Women's NHS Foundation Trust and Wirral University Hospitals Trust). The participants were women with confirmed preterm prelabor rupture of membranes at 16 + 0 to 24 + 0 weeks' gestation. Women with multiple pregnancy, fetal abnormality or obstetric indication for immediate delivery were excluded. Participants were randomly allocated to either serial weekly transabdominal amnioinfusions if the deepest pool of amniotic fluid was < 2 cm or expectant management until 37 weeks' gestation. Short-term maternal, pregnancy and neonatal and long-term outcomes for the child were studied. Long-term respiratory morbidity was assessed using validated respiratory questionnaires at 6, 12 and 18 months of age and infant lung function test at around 12 months of age. Neurodevelopment was assessed using the Bayley Scales of Infant Development, second edition (BSID-II) at corrected age of 2 years.

RESULTS

Fifty-eight women were randomized to the study. Two babies were excluded from the analysis because of termination of pregnancy for lethal anomaly, leaving 56 participants (28 assigned to serial amnioinfusion and 28 to expectant management) recruited between 2002 and 2009. There was no significant difference in perinatal mortality (19/28 vs 19/28; relative risk (RR) 1.0 (95% CI, 0.70-1.43)) and maternal or neonatal morbidity. The overall chance of surviving without long-term respiratory or neurodevelopmental disability was 4/56 (7.1%); 4/28 (14.3%) in the amnioinfusion group and 0/28 in the expectant group (RR 9.0 (95% CI, 0.51-159.70)).

CONCLUSIONS

This pilot study found no major differences in maternal, perinatal or pregnancy outcomes. The study was not designed to show a difference between the groups and the number of survivors was too small to draw any conclusions about long-term outcomes. It does, however, signal that a larger definitive study to evaluate amnioinfusion for improvement in healthy survival is needed. The pilot suggests that, with appropriate funding, such a study is feasible.

Standard- or high-dose oxytocin for nulliparous women with confirmed delay in labour: quantitative and qualitative results from a pilot randomised controlled trial

OBJECTIVE

Evidence suggests that a high dose of oxytocin for nulliparous women at 37-42 weeks of gestation with confirmed delay in labour increases spontaneous vaginal birth. We undertook a pilot study to test the feasibility of this treatment.

DESIGN

Pilot double-blind randomised controlled trial.

SETTING

Three teaching hospitals in the UK.

POPULATION

A total of 94 consenting nulliparous women at term with confirmed delay in labour were recruited, and 18 were interviewed.

METHODS

Women were assigned to either a standard (2 mU/min, increasing every 30 minutes to 32 mU/minute) or a high-dose regimen (4 mU/minute, increasing every 30 minutes to 64 mU/minutes) oxytocin by computer-generated randomisation. Simple descriptive statistics were used, as the sample size was insufficient to evaluate clinical outcomes. The constant comparative method was used to analyse the interviews.

MAIN OUTCOMES MEASURES

The main outcome measures: number of women eligible; maternal and neonatal birth; safety; maternal psychological outcomes and experiences; health-related quality of life outcomes using validated tools and data on health service resource use; incidence of suspected delay of labour (cervical dilatation of <2 cm after 4 hours, once labour is established); and incidence of confirmed delay of labour (progress of <1 cm on repeat vaginal examination after a period of 2 hours).

RESULTS

We successfully developed systems to recruit eligible women in labour and to collect data. Rates of spontaneous vaginal birth (10/47 versus 12/47, RR 1.2, 95% CI 0.6-2.5) and caesarean section (15/47 versus 17/47, RR 1.1, 95% CI 0.6-2.0) were increased, and rates of instrumental birth were reduced (21/47 versus 17/47, RR 0.8, 95% CI 0.5-1.3). No evidence of increased harm for either mother or baby was found. The incidences of suspected delay (14%) and confirmed delay (11%) in labour were less than anticipated. Of those who did not go on to have delayed labour confirmed, all except one woman gave birth vaginally.

CONCLUSIONS

A pilot trial assessing the efficacy of high-dose oxytocin was feasible, but uncertainty remains, highlighting the need for a large definitive trial. The implementation of national guidance of suspected and confirmed delay in labour is likely to reduce intervention.

A re-evaluation of the role of rotational forceps: retrospective comparison of maternal and perinatal outcomes following different methods of birth for malposition in the second stage of labour

OBJECTIVE

To compare the outcomes of operative cephalic births by Kielland forceps (KF), rotational ventouse (RV), or primary emergency caesarean section (pEMCS) for malposition in the second stage of labour in modern practise.

DESIGN

Retrospective observational study.

POPULATION

Data were included from 1291 consecutive full-term, singleton cephalic births between 2 November 2006 and 30 November 2010 with malposition of the fetal head during the second stage of labour leading to an attempt to deliver by KF, RV or pEMCS.

METHODS

Maternal and neonatal outcomes of all KF births were compared with other methods of operative birth for malposition in the second stage of labour (RV or pEMCS).

MAIN OUTCOME MEASURES

Achieving a vaginal birth was the primary outcome and fetal (admission to special care baby unit, low cord pH, low Apgar, shoulder dystocia, Erb's palsy) and maternal (massive obstetric haemorrhage-blood loss of >1500 ml, sphincter injury, length of stay in hospital) safety outcomes were also recorded.

RESULTS

Women were more likely to need caesarean section if RV (22.4%) was selected to assist the birth rather than KF (3.7%; adjusted odds ratio 8.20; 95% confidence interval 4.54-14.79). Births by KF had a rate of adverse maternal and neonatal outcomes comparable to those by RV and pEMCS in the second stage for malposition.

CONCLUSIONS

Our results suggest that, in experienced hands, assisted vaginal birth by KF is likely to be the most effective and safe method to prevent the ever rising rate of caesarean sections when malposition complicates the second stage of labour.

Serious perinatal complications of non-proteinuric hypertension: an international, multicentre, retrospective cohort study

OBJECTIVE

To determine the proportion of births complicated by either a pre-existing or a gestational non-proteinuric hypertension, presenting at <34 weeks' gestation, and the associated incidence with 1 or more serious perinatal complications or birth weight <3rd centile for gestational age.

METHODS

A retrospective chart review was conducted in 5 international centres, from 1998 to 2002, where "tight" control (normalization) of blood pressure (BP) is the norm. International Classification of Diseases (ICD) codes were used to identify women who delivered at > or =20 weeks' gestation, with any hypertensive disorder of pregnancy. Women were included if they had a diastolic blood pressure (dBP) of 90 to 109 mm Hg, due to either a pre-existing or a gestational non-proteinuric hypertension, presenting at <34 weeks' gestation. Women were excluded if they had ongoing severe hypertension, or if at presentation with dBP of 90 to 109 mm Hg, they had 1 or more of the following: proteinuria, an indication for "tight" control of BP or imminent delivery, or a known intrauterine fetal death or lethal fetal anomaly. Data were collected on paper forms, scanned into an electronic database, and summarized descriptively by type of hypertension.

RESULTS

There were 305 eligible women (0.7% deliveries, 12.8% hypertensive deliveries) identified with non-proteinuric hypertension that was either pre-existing (133 [43.6%]) or gestational (172 [56.4%]). Regardless of hypertension type, 16.4% (n = 50) of pregnancies were complicated by birth weight <3rd centile or 1 or more serious perinatal complications, 34.3% (n = 100) by preterm birth, 30.8% (n = 94) by preeclampsia, and 2.0% (n = 6) by serious maternal complications.

CONCLUSION

Non-proteinuric pre-existing or gestational hypertension, presenting before 34 weeks' gestation, identifies a subpopulation of hypertensive pregnant women at both substantial perinatal risk and maternal risk. The CHIPS (Control of Hypertension In Pregnancy Study) trial is designed to determine how best to manage the hypertension of such women in order to optimize perinatal outcome.

St Vincent's Declaration 10 years on: outcomes of diabetic pregnancies

AIMS

To monitor pregnancies in women with pregestational Type 1 diabetes for pregnancy loss, congenital malformations and fetal growth parameters, in a geographically defined area in the north west of England.

METHODS

Population cohort study of 547 pregnancies in women with Type 1 diabetes from maternity clinics in 10 centres over a 5-year period (1995-1999 inclusive). Main outcome measures were numbers and rates of miscarriages, stillbirths, neonatal and post-neonatal deaths; prevalence of congenital malformations; birth weight in relation to gestational age.

RESULTS

Among 547 pregnancies, there were six (1.1%) pairs of liveborn twins, 439 (80.3%) liveborn singletons; 72 (13.2%) spontaneous abortions, 14 (2.6%) stillbirths and 16 (2.9%) terminations. Four of the terminations were performed because of congenital malformations. Both the stillbirth rate (30.1/1000 total births (95% confidence interval (CI) 16.6-50.0)), and prevalence of congenital malformations (84.3/1000 live births (95% CI 60.3-113.8)) were significantly higher than the local population (P < 0.001). When corrected for gestational age, mean birth weight in the sample was 1.3 sd greater than that of infants of non-diabetic mothers (P = 0.12). Infants with congenital malformations weighed less than those without.

CONCLUSION

In an unselected population, the infants of women with pregestational Type 1 diabetes mellitus have 6.4 times the reported risk of a congenital malformation and 5.1 times the reported risk of perinatal mortality than infants in the general population. Further improvements in the management of diabetes and pregnancy in these women are needed if the St Vincent's Declaration target is to be met.

Major postpartum haemorrhage

Postpartum haemorrhage remains in the top five causes of maternal deaths in both developed and developing countries. Persistent blood loss of more than 1000 ml should prompt predetermined measures to achieve resuscitation and haemostasis. A protocol including guidelines is given and volume replacement is discussed. The range of medical and surgical interventions that may be considered for the modern management of major haemorrhage unresponsive to oxytocin and ergometrine are presented. The review discusses in depth the use of misoprostol, recombinant activated factor VII, the uterine tamponade procedures, artery ligation, and uterine haemostatic suturing techniques. It also evaluates the place of interventional radiology and hysterectomy in modern obstetrics.

Risk management on the labour ward

Risk management describes a process whereby the risk of adverse events is eliminated or where the effects of those events are reduced as far as possible. This is particularly relevant to the labour ward setting with respect to intrapartum care.

Computerised analysis of fetal heart rate recordings in maternal type I diabetes mellitus

OBJECTIVE

1. To study computerised cardiotocograph parameters from women with type I diabetes; 2. to examine the significance of observed differences from the expected normal values.

DESIGN

Prospective observational study in the third trimester of pregnancy.

SETTING

The medical antenatal clinic of a tertiary referral centre.

POPULATION

Twenty-six women with type I diabetes mellitus with a singleton pregnancy.

METHODS

Computerised cardiotocograph recordings were made weekly from 28 to 39 weeks. Derived parameters were compared with the published figures for uncomplicated singleton pregnancies. Details of maternal blood sugar, labour and delivery and neonatal outcome were recorded. Data were compared between groups according to the computerised analysis of the antenatal CTGs.

RESULTS

One-hundred and thirty-one recordings were made with a median of five per patient (range 1-12). 1 1.3% showed absent episodes of high variation compared with the expected value of 0.8%, a difference of 9.5% (95% CI 4.5-15.3). Differences in short term variation, basal heart rate, frequency of fetal movements and heart rate accelerations were also found which changed with gestation. Overall these changes represented a more immature form of fetal heart rate than that which would be expected. No relationship between the changes and adverse fetal outcome could be identified.

CONCLUSIONS

Significant differences exist in cardiotocographs in maternal type I diabetes compared with normal fetuses. The changes may represent a delay in fetal maturation. The analysis mode of the computer will register these as abnormal features, but there is no evidence that they are pathological. We would recommend that computerised analysis is not used to assess pregnancies complicated by maternal type I diabetes mellitus.

Counselling following the Prenatal Diagnosis of Klinefelter Syndrome: Comparisons between Geneticists and Obstetricians in Five European Countries

Objective: To describe and compare the information obstetricians and geneticists in five European countries report they would give following the prenatal diagnosis of Klinefelter syndrome. Methods: 388 obstetricians and 269 geneticists from Germany, the Netherlands, Portugal, Spain and the UK completed a brief questionnaire assessing two variables: the information they reported providing to parents following the prenatal diagnosis of Klinefelter syndrome (categorized as positive or negative); and their perceptions of the quality of life with the condition. Results: Geneticists were more likely than obstetricians to report providing more positive than negative information about Klinefelter syndrome than equal amounts of positive and negative information or more negative than positive information about the condition (excess positive information). Regardless of specialty, the information that health professionals reported providing was predicted by their perceptions of the quality of life with the condition, and the country from which they came. Those perceiving quality of life as greater were more likely to provide an excess positive information, as were health professionals from Germany and the UK. Conclusions: These results suggest that the information parents across Europe receive after the prenatal diagnosis of Klinefelter syndrome varies according to the specialty and country of the health professionals consulted, and their perceptions of quality of life with the condition. This variation seems to reflect personal, cultural and professional differences between health professionals. Copyright 2002 S. Karger AG, Basel

Congenital cystic adenomatoid malformation of the lung coexisting with recombinant chromosome 18. A case report

OBJECTIVE

Diagnosis of congenital cystic adenomatoid malformation of the lung (CCAM) in association with recombinant chromosome 18.

METHOD

Ultrasound diagnosis of a CCAM and hydrops was made. The mother was known to have a pericentric inversion of chromosome 18 and had a previous pregnancy with a recombinant chromosome 18 (partial deletion of 18p and partial duplication of 18q). Cordocentesis for karyotype was therefore performed.

RESULT

Fetal karyotype revealed a recombinant chromosome 18, this time with partial deletion of 18q and partial duplication of 18p. Postmortem confirmed a type III CCAM and a septum primum atrial defect.

CONCLUSIONS

Although deletion/duplication of chromosome 18 is commonly associated with a wide variety of anomalies, the association with CCAM is an unusual one. Fetal and parental karyotyping should be considered in cases of CCAM, because fetal therapy is increasingly being considered in these pregnancies. Current management of parents with pericentric inversions must rely on invasive diagnostic testing in the second trimester because predicting the likelihood of an unbalanced karyotype and phenotype in a fetus is difficult.

Pregnancy does not adversely affect renal transplant function

Women with functioning transplanted kidneys often become fertile again. Indeed, renal function, endocrine status and libido rapidly improve after renal transplantation, and 1:50 women of childbearing age become pregnant. However, there is concern regarding the haemodynamic changes of pregnancy, which could lead to a decline in graft function (temporary or permanent). We examined obstetric data and renal parameters in 29 patients and 33 pregnancies. Mean serum creatinine and creatinine clearance remained stable throughout pregnancy and 1 year postpartum. However, there was a significant increase in proteinuria from a mean of 0.45 g/24 h around the time of conception to 1.11 g/24 h at delivery (p<0.05). The proteinuria resolved to baseline levels at 3 months postpartum. We highlight certain parameters to be considered before conception to allow a good obstetric outcome and prolong stable renal function: serum creatinine <150 micromol/l, proteinuria <1 g/day, absence of histological evidence of chronic allograft rejection, controlled blood pressure (140/90) and stability of maintenance immunosuppression.

Outcome of congenital lung abnormalities detected antenatally

To determine the outcome of congenital lung abnormalities, data were collected retrospectively between January 1991 and December 1996 on any foetus found to have a lung lesion on antenatal ultrasound. A total of 23 foetuses had lung lesions on antenatal ultrasound. In two foetuses the antenatal ultrasound showed bilateral enlarged "bright" echogenic lungs with evidence of hydrops. Both pregnancies were terminated and tracheal atresia was confirmed. In 15 foetuses the antenatal ultrasound appearance was of a unilateral "bright" echogenic lung. There was one case of bronchial atresia and two cases of congenital lobar emphysema, which all had surgery. In nine cases there was a reduction in the size of the lesion on serial antenatal ultrasounds and no lesion was detected after birth. In three cases a small lesion was present after birth on chest radiography. In six foetuses the antenatal ultrasound appearance was of unilateral cystic or mixed cystic and echogenic lung lesions. Two pregnancies were terminated; both had congenital cystic adenomatoid malformation. Four pregnancies were continued and three infants had surgery soon after birth and were confirmed to have had congenital cystic adenomatoid malformation. One infant has been managed conservatively. In conclusion, a definitive diagnosis cannot usually be made antenatally. A large lesion on initial scan does not necessarily predict a poor outcome. The natural history of small asymptomatic postnatal lesions is unknown and a long-term prospective study is needed to determine the outcome of these lesions.

Partogram action line study: a randomised trial

OBJECTIVE

To assess the effect of three different partograms on caesarean section and maternal satisfaction.

DESIGN

Prospective randomised clinical trial.

SETTING

Regional teaching hospital in North West of England.

PARTICIPANTS

Nine hundred and twenty-eight primigravid women with uncomplicated pregnancies who presented in spontaneous labour at term.

INTERVENTIONS

The women were randomised to have their progress of labour recorded on a partogram with an action line 2, 3 or 4 hours to the right of the alert line. If the progress reached the action line, a diagnosis of prolonged labour was made. Prolonged labour was managed according to the standard ward protocol.

MAIN OUTCOME MEASURES

Primary: Caesarean section rate and maternal satisfaction; secondary: need for augmentation, duration of labour, analgesia, cord blood gas analysis, postpartum haemorrhage, number of vaginal examinations, Apgar score and admission to special care baby unit.

RESULTS

Caesarean section rate was lowest when labour was managed using a partogram with a 4-hour action line. The difference between the 3- and 4-hour partograms was statistically significant (OR 1 8, 95% CI 1.1-3.2), but the difference between 2 and 4 hours was not (OR 1.4, 95% CI 0.8-2.4). The women in the 2-hour arm were more satisfied with their labour when compared to the women in the 3-hour (P < 00001) and 4-hour (P <00001) arm.

CONCLUSION

Our data suggest that women prefer active management of labour. It is possible that partograms which favour earlier intervention are associated with higher caesarean section rate. As the evidence on which to base the choice of partograms remains inconclusive further research is required.

Second trimester serum free beta human chorionic gonadotrophin levels as a predictor of pre-eclampsia

BACKGROUND

To prospectively assess maternal serum free beta human chorionic gonadotrophin (beta hCG) estimation between 15 and 18 weeks gestation, as a screening test for pre-eclampsia in primigravid women.

METHODS

A prospective longitudinal study in a University Teaching Hospital. The study population was 430 primigravid women, who had maternal serum free beta hCG levels measured as part of antenatal serum screening for Down's Syndrome in the second trimester, who booked consecutively within the unit and went on to deliver on the unit's labor ward. These women were followed during their subsequent pregnancy and categorized into those who remained normotensive and those who developed pre-eclampsia on both clinical and biochemical grounds. The beta hCG levels were used to construct a receiver operator characteristics curve (ROC) to assess the screening potential for pre-eclampsia.

RESULTS

Nineteen (4.4%) women in the study group developed pre-eclampsia. The median second trimester free beta hCG multiples of the median (MOM) was significantly elevated compared to that of the control group (1.52 vs 1.10, p=0.03). The ROC curve shows that for a sensitivity of 79%, the specificity was only 54%.

CONCLUSIONS

Maternal serum free beta hCG alone measured in the second trimester is not clinically useful as a screening test for pre-eclampsia in primigravid women. It has, however, some predictive value.

Dysfunctional labour: a randomised trial

Sixty-one women making slow progress in the active phase of spontaneous labour with intact membranes were randomised to oxytocin and amniotomy, amniotomy only or expectant management. The data show that oxytocin significantly increases the rate of cervical dilatation and shortens prolonged labour, when compared with amniotomy alone and expectant management (P = 0.0144 and 0.0006, respectively). The impact on the operative delivery rate and neonatal outcome is difficult to assess due to the small number of relevant adverse outcomes. Women reported higher satisfaction score in the two groups where intervention followed the diagnosis of dysfunctional labour.

Outcomes of pregnancy in insulin dependent diabetic women: results of a five year population cohort study

OBJECTIVE

To monitor pregnancies in women with pre-existent insulin dependent diabetes for pregnancy loss, congenital malformations, and fetal growth in a geographically defined area of north west England.

DESIGN

Population cohort study.

SETTING

10 maternity units in Cheshire, Lancashire, and Merseyside which had no regional guidelines for the management of pregnancy in diabetic women.

SUBJECTS

462 pregnancies in 355 women with insulin dependent diabetes from the 10 centres over five years (1990-4 inclusive).

MAIN OUTCOME MEASURES

Numbers and rates of miscarriages, stillbirths, and neonatal and postneonatal deaths; prevalence of congenital malformations; birth weight in relation to gestational age.

RESULTS

Among 462 pregnancies, 351 (76%) resulted in a liveborn infant, 78 (17%) aborted spontaneously, nine (2%) resulted in stillbirth, and 24 (5%) were terminated. Of the terminations, nine were for congenital malformation. The stillbirth rate was 25.0/1000 total births (95% confidence interval 8.9 to 41.1) compared with a population rate of 5.0/1000, and infant mortality was 19.9/1000 live births (5.3 to 34.6) compared with 6.8/1000. The prevalence of congenital malformations was 94.0/1000 live births (63.5 to 124.5) compared with 9.7/1000 in the general population. When corrected for gestational age, mean birth weight in the sample was 1.3 standard deviations greater than that of infants of non-diabetic mothers. Infants with congenital malformations weighed less than those without.

CONCLUSION

In an unselected population the infants of women with pre-existent insulin dependent diabetes mellitus have a 10-fold greater risk of a congenital malformation and a fivefold greater risk of being stillborn than infants in the general population. Further improvements in the management of pregnancy in diabetic women are needed if target of the St Vincent declaration of 1989 is to be met.

Antenatal and neonatal renal vein thrombosis: new ultrasonic features with high frequency transducers

The ultrasonic appearances of two infants with renal vein thrombosis (RVT) are described. One infant presented in the neonatal period and one antenatally. Consistent with previous reports, one or both kidneys were enlarged, with a generalised increase in echogenicity and vascular or perivascular streaking compatible with interlobular and arcuate vessel occlusion. Using high frequency transducers (7. 0-10 MHz), we identified new features during the course of the disease. The apex of the renal papilla became hypo-echoic and there was a ring of reduced echogenicity around the affected pyramids 1-2 weeks after the acute phase. These features correlate with the known pathophysiological course of RVT, but have not been previously described using ultrasound. The features are illustrated and the mechanism is discussed.

The presence of fetal fibronectin in the cervicovaginal secretions of women at term--its role in the assessment of women before labor induction and in the investigation of the physiologic mechanisms of labor

OBJECTIVE

Our purpose was to determine whether the presence of fetal fibronectin in cervicovaginal secretions of patients undergoing induction of labor reflected the cervical state and ultimately the ease of induction of labor.

STUDY DESIGN

A prospective observational study of 103 patients undergoing induction of labor at term was conducted at Liverpool Maternity Hospital, a large university teaching hospital. We studied the women after 37 completed weeks of pregnancy. A Dacron (Adeza Biomedical, Sunnyvale, Calif.) polyester swab specimen was first taken from the endocervix for assessment of the presence of the fetal fibronectin. The cervix was then assessed by digital vaginal examination and scored with a modified Bishop's score. The fetal fibronectin swab was processed at the bedside with a membrane immunoassay kit specific for fetal fibronectin. A score was ascribed depending on the strength of the fibronectin reaction determined by the intensity of the color change on the plate, the presence of fetal fibronectin resulting in a score of 1 to 4. The patient was subsequently managed according to the standard induction protocol of the unit. The clinicians involved in the patient's care were blind to the result of the fetal fibronectin swab.

RESULTS

There was a good correlation between the modified Bishop's score and the fetal fibronectin score (r = 0.58, p < 0.001). To predict a latent phase of < 8 hours, a fetal fibronectin score of 3 or 4 has a sensitivity of 73% with a specificity of 83% and a modified Bishop score of > or = 4 has a sensitivity of 75% and a specificity of 73%. For delivery within 12 hours of induction of labor a fetal fibronectin score of > or = 3 has a sensitivity of 61% and specificity of 83% compared with the modified Bishop score of > or = 4, which has a sensitivity of 76% and a specificity of 72.5%.

CONCLUSIONS

The fetal fibronectin score is as good as the modified Bishop score as an index of the ease with which induction of labor may be performed. This would imply that it also reflects the proximity of the onset of labor. The presence of fetal fibronectin cervicovaginal secretions is therefore a marker of the changes in the cervix and membranes that precede labor regardless of the gestational age.

Fetal echogenic lung lesions: prenatal ultrasound diagnosis and outcome

The differential diagnosis of echogenic areas in the fetal chest include congenital diaphragmatic hernia (CDH), cystic adenomatoid malformation (CAM), sequestrated lung and tracheal or bronchial atresia. The purpose of this study was to evaluate the accuracy of prenatal diagnosis and document outcome in fetuses with echogenic chest lesions. Seventeen fetuses with echogenic chest masses were seen in our unit between 17 and 36 weeks' gestation over a 5-year period. We reviewed these cases retrospectively for prenatal diagnosis, postnatal diagnosis and outcome. Prenatal diagnosis was correct in 13 fetuses, with CDH in 8, sequestrated lung in 4 and tracheal atresia in 1. Four fetuses had incorrect or uncertain prenatal diagnoses. In three fetuses CDH and CAM could not be differentiated. After delivery two of these had CDH and one had sequestrated lung. One fetus with bilateral lesions had prenatal diagnosis of bilateral CAM. Post-mortem examination revealed tracheal atresia as part of Fraser syndrome. All five babies with sequestrated lung are well and none required surgery. Ten fetuses had CDH, two pregnancies were terminated, one died in utero, five died as neonates and two babies survived following surgery. The study reveals that in a minority of fetuses CDH and CAM could not be differentiated prenatally. We agree with recent reports of fetal sequestrated lung describing sonographic improvement in utero. A large lesion on initial scan does not necessarily predict a poor neonatal outcome in this condition. This, together with the poor outcome in fetuses with echogenic CDH and tracheal atresia, has important implications for prenatal counselling.

Isolated choroid plexus cysts--the need for routine offer of karyotyping

The management of isolated fetal choroid plexus cysts remains controversial. We have prospectively studied 15,565 pregnancies at two large obstetric units for the presence of choroid plexus cysts. In all cases where cysts were present at 19 weeks' gestation or greater, and were multiple, bilateral or solitary and greater than 5 mm maximum diameter, women were offered amniocentesis or placental biopsy, irrespective of the presence or absence of other abnormalities. Choroid plexus cysts were present in 152 (0.98 per cent) of cases. Four cases (2.6 per cent) of autosomal trisomy (three of trisomy 18, one of trisomy 21) were detected on prenatal karyotyping. In all cases, choroid plexus cysts were the only detectable prenatal anomaly. This study and a review of other large studies do not support the view that isolated choroid plexus cysts are a benign variant, the risk of trisomy being 1 in 82. Until further evidence is available, we recommend that cases of isolated fetal choroid plexus cysts at 19 weeks' gestation or greater should be offered prenatal karyotyping.

Phenytoin prophylaxis in severe pre-eclampsia and eclampsia

OBJECTIVE

To determine plasma phenytoin levels and seizure outcome in women given phenytoin for seizure prophylaxis in severe pre-eclampsia and eclampsia.

DESIGN

Prospective observational study comparing two phenytoin loading regimens.

SETTING

Two UK teaching hospitals.

SUBJECTS

Sixty-seven consecutive women with severe pre-eclampsia and five with eclampsia.

INTERVENTIONS

The first 29 women were given a 15 mg/kg intravenous loading dose of phenytoin. The next 43 received 17.5 mg/kg. All were given 500 mg phenytoin 12 h after completion of the loading dose and then 250 mg every 12 h for four doses.

MAIN OUTCOME MEASURES

Total plasma phenytoin levels at 30 min, 6 h and 12 h after loading dose, 6 h after first maintenance dose and on days 2 and 3 of maintenance therapy; eclamptic seizures after starting phenytoin.

RESULTS

Mean plasma phenytoin levels were higher at 30 min and 6 h after the 17.5 mg/kg loading dose. Nine of 29 (31%) phenytoin levels 30 min after the loading dose were above the therapeutic range in the 15 mg/kg group compared with 26/38 (68%) in the 17.5 mg/kg group (P < 0.01). Six of 27 (22%) phenytoin levels 12 h after the loading dose were subtherapeutic in the 15 mg/kg group compared with 2/38 (5%) in the 17.5 mg/kg group (P < 0.05). Three women, two in the 17.5 mg/kg group, developed seizures after starting phenytoin. All three had plasma levels within the therapeutic range.

CONCLUSIONS

Compared with a loading dose of 17.5 mg/kg, loading with 15 mg/kg phenytoin was associated with a lower incidence of high plasma levels at 30 min but a higher incidence of subtherapeutic levels at 12 h. Seizures occur in 2 to 3% of pre-eclamptics despite apparently therapeutic phenytoin levels.

Undiagnosed breech

OBJECTIVES

To assess the proportion of breech presentations diagnosed in labour and to compare their outcomes with those diagnosed prior to the onset of labour.

DESIGN

Retrospective casenote review.

SETTING

Mill Road Maternity Hospital, a teaching hospital in central Liverpool.

SUBJECTS

Three hundred and five singleton breech presentations delivered in the hospital between January 1988 and July 1991; 226 cases prior to the onset of labour and 79 cases diagnosed for the first time in labour.

MAIN OUTCOME MEASURES

Rates of vaginal delivery and caesarean section, birthweight, short term morbidity as assessed by trauma, signs of cerebral irritation and admission to the newborn intensive care unit (NBICU), and Apgar scores.

RESULTS

Breech presentations diagnosed for the first time in labour were more likely to deliver vaginally than those assessed and allowed to go into labour (odds ratio 1:68 95% CI 1.0-3.0). This difference was not due to demographic variables or differences in birthweight. There was no short term morbidity attributable to vaginal breech delivery.

CONCLUSION

A significant number of breech presentations are not detected until labour despite rigorous antenatal surveillance. Our results show that undiagnosed breeches may not be important as they are more likely to deliver vaginally, with no excess morbidity or mortality, compared to diagnosed breeches in labour, carefully assessed for vaginal delivery. There are, therefore, no grounds for delivering all undiagnosed breeches by caesarean section.

The prediction of fetal compromise and acidosis by biophysical profile scoring in the small for gestational age fetus

In a prospective blind study, 133 fetuses suspected of being small for gestational age (SGA), defined as an estimated fetal weight less than the 10th centile for gestation, were monitored by weekly biophysical profile assessment. Perinatal outcome was assessed by umbilical venous blood pH estimation and compared with the profile score determined within seven days of delivery. The positive and negative predictive values of the full biophysical profile score were not significantly better than combinations of two or three of the individual components in this group of fetuses. The use of amniotic fluid volume, non-stress testing and either fetal movement or breathing offers an acceptable alternative to full biophysical profile assessment in the fetus suspected of being small for gestation.