First-trimester prenatal sonographic findings associated with OEIS (omphalocele-exstrophy-imperforate anus-spinal defects) complex: a case and review of the literature

First-trimester sonographic findings associated with omphalocele-exstrophy-imperforate anus-spinal defects (OEIS) complex and review of the literature regarding this rare congenital anomaly are presented.

Sudden fetal death in women with well-controlled, intensively monitored gestational diabetes

An intensive antepartum monitoring system for women with gestational diabetes mellitus was evaluated over a 5-year period. Early diagnosis and liberal treatment with insulin was concomitantly followed with non-stress testing: weekly from 28 to 34 weeks' gestation and semi-weekly thereafter. Despite maternal euglycemia and satisfactory antepartum assessment, three fetal deaths occurred within 72 hours of reassuring fetal monitoring. Additionally, 24 (7%) fetuses were delivered on the basis of a low biophysical profile score (less than 6) at term. The stillbirth rate for women with gestational diabetes was 7.7/1000, whereas the stillbirth rate for nondiabetic low-risk patients was 4.8/1000. Women with gestational diabetes continue to be in a high-risk category for antepartum fetal death, requiring intensive monitoring with consideration for timely delivery.

Clinical management of the fetus with markedly diminished umbilical artery end-diastolic flow

This study was conducted to evaluate prospectively a management protocol for fetuses with a markedly abnormal umbilical artery velocity waveform. The study population consisted of fetuses whose systolic/diastolic ratio was greater than 2 SD above the mean for gestational age. The matched control population consisted of fetuses with similar gestational ages, indications for testing, and estimated fetal weights with normal systolic/diastolic ratios. Abnormal Doppler results were used only to determine the frequency of fetal testing. Biophysical profile testing was performed semiweekly on all patients. Patients with absent or reversed end-diastolic flow were admitted for daily testing. The following criteria were used as indications for delivery: (1) worsening maternal condition, (2) oligohydramnios, (3) intrauterine growth retardation with lung maturity, and (4) biophysical profile score less than or equal to 4. Fifty-one patients (7%) had abnormal Doppler blood flow velocity studies. When the study population was compared with the control population at the time of delivery, there were no differences in umbilical artery pH, Apgar score, or incidence of intrauterine growth retardation. However, study patients were delivered at a significantly lower gestational age and lower birth weight and experienced a higher likelihood of neonatal intensive care unit admission. When study patients with documented end-diastolic flow were compared with study patients with no end-diastolic flow, there were no differences in umbilical artery pH, Apgar score, or incidence of intrauterine growth retardation. However, fetuses with no end-diastolic flow had a significantly shorter test-to-delivery interval, lower gestational age, lower birth weight, and more neonatal intensive care unit admissions. There were no perinatal deaths among the study patients. The range of systolic/diastolic ratios for the five patients who failed to follow our protocol for intensive maternal-fetal surveillance was 4.3 to infinity; all experienced fetal death within 18 days. These results suggest that immediate delivery of the fetus with diminished end-diastolic flow may not be mandatory. The combined use of fetal biophysical testing and commonly used criteria for delivery results in acceptable fetal outcome and prolongation of gestational age.

Discordant twins--a prospective study of the diagnostic value of real-time ultrasonography combined with umbilical artery velocimetry

This study was undertaken to evaluate the role of Doppler velocimetry combined with intertwin differences in ultrasonographically derived estimated fetal weight, biparietal diameter, abdominal circumference, and femur length as a comprehensive test for the prediction of discordancy. The following cutoff values were used to indicate abnormal test results: delta biparietal diameter greater than 6 mm, delta abdominal circumference greater than 20 mm, delta femur length greater than 5 mm, delta estimated fetal weight greater than 15%, and delta systolic/diastolic ratio greater than 15%. Discordancy was identified when the birth weight difference exceeded 15%. The study population consisted of 58 consecutively evaluated third-trimester twin gestations. Eighteen sets of twins were discordant. None of these tests was uniformally successful in identifying twin discordancy; in three instances, all test results were normal. The diagnostic accuracy provided by ultrasonography was not significantly different from that provided by Doppler velocimetry. Overall the best predictor appeared to be the presence of either delta systolic/diastolic ratio greater than 15% or delta estimated fetal weights greater than 15%, which correctly identified 14 of the 18 discordant twins and misclassified only five of the 40 concordant pairs. This combination also had the highest positive and negative predictive values (73% and 90%, respectively).

Macrosomia in the postdate pregnancy: is routine ultrasonographic screening indicated?

Macrosomia is a potential but often overlooked consequence of the postdate pregnancy. A total of 317 consecutive patients with well-dated pregnancies who were seen because of fetal surveillance at greater than 41 weeks' gestation had an estimation of the fetal weight based on femur length and abdominal circumference at the initial visit. The incidence of macrosomia at 41 weeks' gestation was 25.5%. There was a higher incidence of cesarean section because of arrest and protraction disorders in the postdate pregnancies in which the infant was macrosomic (22%) versus those in which the infant was not macrosomic (10%, p less than 0.01). In a control group of 100 consecutive women delivered between 38 and 40 weeks' gestation, the incidence of macrosomia was 4%, significantly lower than the rate in the postdate patients (p less than 0.01). Incidence of cesarean section because of arrest and protraction disorders was significantly lower in this group (6%, p less than 0.05). The sensitivity and specificity of an estimated fetal weight greater than 4000 gm to predict a birth weight greater than 4000 gm were 60.5% and 90.7%, respectively, with a positive predictive value of 70% and a negative predictive value of 87%. We conclude that routine ultrasonographic screening for macrosomia may be a valuable adjunct to current fetal surveillance protocols used in the postdate pregnancy.

Fatal intrapartum pulmonary embolus during tocolysis

Intrapartum pulmonary embolus, especially in association with hypercapnea, is an extremely dangerous situation requiring immediate detection and aggressive management. The predisposing factors of obesity and bed rest must be assessed, with strong consideration given to the use of prophylactic heparin.