Faculty Bibliography

This study was designed to determine whether umbilical artery levels of both interleukin-6 (IL-6) and soluble intracellular adhesion molecule-1 (sICAM-1) correlate with levels in the umbilical vein. Paired umbilical artery-vein specimens were assayed for IL-6 and sICAM-1. The paired-sign test was used to compare umbilical artery vein levels of IL-6 and sICAM-1. Spearman rank correlation was used to determine relationships between paired umbilical artery-vein levels for a variety of clinical subgroups. For 23 paired samples overall, umbilical artery levels were greater than corresponding vein levels for both IL-6 (P = .039) and sICAM-1 (P = .035). Artery-vein correlations were significant for IL-6 (rho = 0.845, P = .001) and sICAM-1 (rho = 0.806, P = .0002). Correlations were not influenced by prematurity, route of delivery, labor, or neonatal sepsis. In conclusion, umbilical artery levels of IL-6 and sICAM-1 correlate significantly with umbilical vein levels.

The objective of this study was to determine the effects of removal of amniotic fluid in cases of symptomatic severe polyhydramnios on Doppler waveform indices of the uterine and umbilical arteries and flow velocities of the uterine arteries. Nine women underwent therapeutic amniocentesis during ten pregnancies for symptomatic polyhydramnios due to Beckwith-Wiedemann Syndrome (n = 1), esophageal atresia (n = 2), chorioangioma (n = 1), twin-twin transfusion syndrome (n = 3), a presumed autosomal recessive syndrome (n = 2), and an unbalanced double translocation (n = 1; partial dup 3q and partial del 9p syndrome). An average of 2.78 +/- 0.9 (range 1-4) 1 of fluid were removed at each procedure between the gestational ages of 18 and 34 weeks (mean of 28 weeks). The systolic/diastolic (S/D) ratio, pulsitility index (PI), and resistance index (RI) of the uterine and umbilical arteries were obtained before and after the procedure using color and pulsed Doppler. After angle correction, the peak systolic velocity (PSV) and mean velocity (MV) in centimeters/second (cm/s) of the uterine arteries were also determined. The presence or absence of a uterine artery waveform notch was determined. Dominant uterine arteries were defined as those with lower impedance indices or higher flow velocities. Statistical analysis was performed with the Wilcoxon signed-rank test. Significance was set at P < 0.05. There was a significant increase in the median value of the uterine artery MV (43.8 vs. 81.1 cm/s, P = 0.005) and PSV (74.2 vs. 125.5 cm/s, P = 0.007) after amniocentesis. The uterine S/D (3.0 vs. 1.84, P = 0.007), PI (1.12 vs. 0.68, P = 0.008), and RI (0.60 vs. 0.45, P = 0.005) impedance indices significantly decreased following amniocentesis. When uterine arteries were categorized as dominant vs. nondominant, there were greater improvements in impedance indices and flow velocities in the nondominant uterine arteries. There were three cases of unilateral and one case of bilateral early diastolic notches of the uterine artery waveforms which either resolved (n = 4) or improved (n = 1). There was no effect on the umbilical artery impedance indices. Therapeutic amniocentesis significantly improved uterine artery impedance indices and resulted in improved flow velocities, while there was no effect on umbilical artery waveform indices. The procedure resulted in the disappearance or improvement of the uterine waveform notch. Our findings suggest that in cases of severe polyhydramnios abnormal uterine artery velocimetry may not be due to lack of trophoblastic invasion of the spiral arteries but to increased intrauterine pressure secondary to polyhydramnios

Bronchopulmonary sequestration is a congenital abnormality of nonfunctional pulmonary tissue that lacks normal connections with the bronchial tree. The sequestered tissue typically receives the majority of its blood supply from systemic vessels, most often the distal thoracic or upper abdominal aorta. These lesions often are associated with fetal hydrops, polyhydramnios, and persistent masses postnatally. Bronchopulmonary sequestrations are thought to require resection owing to their predisposition for chronic pulmonary infections later in life. However, spontaneous in utero resolution of these lesions can occur. This report describes the real time, color Doppler, and duplex Doppler ultrasonographic investigation of an intrathoracic bronchopulmonary sequestration that resolved spontaneously. Our investigation of this case provides new insight into a possible mechanism for spontaneous regression of bronchopulmonary sequestration

OBJECTIVE: Our purpose was to describe the relative contributions and characteristics of various subgroups of patients to the overall repeat cesarean delivery rate and to determine modifiable practice patterns that might lead to fewer repeat cesarean deliveries. STUDY DESIGN: Hospital records of all women with a previous cesarean section who were delivered between Jan. 1 and June 30, 1994, at St. Peter's Medical Center in New Brunswick, New Jersey, were reviewed. Four groups were identified: (1) elective repeat cesarean, (2) 'indicated' repeat cesarean, (3) failed vaginal birth after cesarean, and (4) successful vaginal birth after cesarean. Descriptive and outcome data were collected. RESULTS: There were 406 patients, 376 of whom had complete records available for review. Of these, 235 had a repeat cesarean delivery because of the following reasons: elective (107, 45%), 'indicated' (56, 24%), and failed vaginal birth after cesarean (72, 31%). The remaining 141 patients had a vaginal birth after cesarean. Patients with private or health maintenance organization insurance were nearly seven times more likely to have a repeat cesarean delivery as an elective procedure as compared with Medicaid or self-pay patients (odds ratio 6.88, 95% confidence interval 2.33 to 20.38). The failed vaginal birth after cesarean group was characterized by more frequent inductions of labor, less use of amniotomy, and very early epidural placement. CONCLUSIONS: Examination of patient characteristics is required to identify population-specific strategies to reduce repeat cesarean delivery rates. Modifiable practice patterns exist that may lead to interventions to reduce repeat cesarean delivery rates

The management of pregnancies complicated by premature rupture of the membranes (PROM) should include some type of surveillance for the development of infectious complications. This is a necessity because neonatal sepsis is not heralded by maternal chorioamnionitis in the majority of cases. Fetal biophysical assessment holds promise as a method to assess fetal well-being and predict the development of infectious complications. The frequent use of fetal biophysical profiles in patients with PROM helps to distinguish healthy fetuses from those infected or at high risk of infection. This distinction enables the physician to intervene appropriately and in a timely manner. The recognition of the healthy fetus allows for safe prolongation of pregnancy. This article reviews the published experience using antepartum fetal biophysical monitoring in patients with PROM

OBJECTIVE: Our purpose was to determine whether perioperative transvaginal ultrasonographic evaluation of the incompetent cervix treated with emergency cerclage is predictive of pregnancy outcome. STUDY DESIGN: Twenty-nine women who underwent emergency cerclage at 16 to 26 weeks of gestation had transvaginal ultrasonographic evaluation of the cervix within 48 hours before and after surgery and at least three times thereafter until 28 weeks of gestation. The following measurements were obtained: (1) funnel width, (2) funnel length, (3) endocervical canal length, (4) the distance between the internal and external os, (5) upper cervix (length of closed endocervical canal above the cervical cerclage), (6) lower cervix (endocervical canal length below suture), and (7) cervical index (1+ Funnel length/Endocervical canal length). Values are reported as the median in millimeters, and statistical analysis was performed by use of the Mann-Whitney U test, Wilcoxon signed-rank test, Spearman rank correlation, 2 x 2 contingency tables, and multiple regression analysis with significance set at p < 0.05. RESULTS: Cerclage procedures resulted in significant improvement in postoperative median measurements of funnel width (15 vs 4.0 mm, p < 0.0001), funnel length (29 vs 3 mm, p < 0.0001), and endocervical canal length (2 vs 27 mm, p < 0.0001). There was a significant relationship between gestational age at delivery and the following measurements: preoperative funnel width (r = -0.51, p = 0.007), postoperative endocervical canal length (r = 0.39, p = 0.04), length of the lower cervix (r = 0.39, p = 0.038), and the cervical index (r = -0.39, p = 0.038). An upper cervical length < 10 mm was a good predictor of delivery before 36 weeks of gestation, sensitivity 85.7% (12/14), specificity 66.7% (10/15), positive predictive value 70.6% (12/17), negative predictive value 83% (10/12), and Fisher's exact p = 0.008. Postoperatively all patients had upper cervical lengths < 10 mm by 28 weeks of gestation. Preoperative digital assessments of cervical dilatation before surgery did not correlate with gestational age at birth (r = -0.031, p = 0.36). CONCLUSIONS: In cases of cervical incompetence treated with emergency cerclage, perioperative transvaginal ultrasonographic assessment of the cervix reveals that the procedure results in improved ultrasonographic status of the cervix and that the ultrasonographic cervical findings before and after surgery correlate with pregnancy outcome

OBJECTIVE:Plasminogen activator inhibitor-1, the major serum protease inhibitor of fibrinolysis, increases steadily during pregnancy. The study objective was to examine four hormones, namely, estradiol-17 beta, progesterone, prolactin, and hydrocortisone to determine their individual contributions in the production of tissue plasminogen activator antigen, plasminogen activator inhibitor-1 antigen, and plasminogen activator inhibitor-1 activity. STUDY DESIGN/METHODS:Human umbilical vein endothelial cells were grown with physiologic third-trimester concentrations of the above hormones, and fibrinolytic parameters were measured. RESULTS:Of the four hormones evaluated, only hydrocortisone significantly increased plasminogen activator inhibitor-1 antigen and activity at both concentrations tested (p < 0.001). Estradiol-17 beta significantly increased tissue plasminogen activator antigen and progesterone significantly decreased tissue plasminogen activator antigen, but neither affected the overall fibrinolytic balance. CONCLUSION/CONCLUSIONS:Hydrocortisone demonstrated antifibrinolytic properties at physiologic concentrations in pregnancy, suggesting that there may be a role for hydrocortisone in the prothrombotic tendency associated with pregnancy. The overall process of fibrinolysis was unaffected by estradiol-17 beta, progesterone, or prolactin.

OBJECTIVE: To determine the efficacy of individual fetal heart rate (FHR) indices, as determined by computer analysis of the FHR tracing, in detecting fetal acidemia at birth in growth-restricted fetuses. METHODS: The study population consisted of 38 growth-restricted fetuses at 26-37 weeks' gestation from pregnancies with abnormal uterine and/or umbilical artery Doppler velocimetry. The 1-hour FHR tracing was analyzed by computer within 4 hours of cesarean birth before the onset of labor. Umbilical artery cord blood was collected at birth, and pH was determined within 5 minutes of collection. RESULTS: On linear regression, the duration of episodes of low variation in minutes (r = -0.77, r2 = 0.59) and short-term (r = 0.72, r2 = 0.52) and long-term (r = 0.69, r2 = 0.47) variation in milliseconds were significantly related to umbilical artery pH at birth, and more so than the number of accelerations of ten (r = 0.57, r2 = 0.32) and 15 (r = 0.38, r2 = 0.14) beats per minute. There were significant differences in computer measurements of FHR accelerations and variation between the umbilical artery pH categories of acidemia (pH less than 7.20), preacidemia (7.20-7.25), and nonacidemia (greater than 7.25). Stepwise regression revealed that episodes of low variation best described the model for predicting umbilical artery pH at birth (P < .001), with no improvement provided by the addition of other computer-analyzed FHR characteristics. CONCLUSION: In this population of growth-restricted fetuses delivered by elective cesarean, the computer indices of duration of episodes of low variation and short-term and long-term variation were significantly associated with umbilical artery pH and predicted umbilical artery acidemia at birth

OBJECTIVE: To establish the efficacy of second-trimester fetal long-bone biometry (femur, humerus, tibia, and fibula length) in detecting trisomy 21 and to generate tables for adjusting the risk of trisomy 21 according to long-bone biometry. METHODS: Four long-bones--femur, humerus, tibia, and fibula--were measured ultrasonically in singleton fetuses before genetic amniocentesis. Fetuses with normal karyotypes were used to derive regression equations describing predicted lengths on the basis of the biparietal diameter measurement. The efficacy of each abnormally short bone, alone and in combination, was determined in 22 fetuses with trisomy 21 encountered during the study period. After the sensitivity and specificity of long-bone biometry were established, appropriate tables were generated by Bayes' theorem to adjust the risk of trisomy 21 in the second trimester depending on long-bone biometry. RESULTS: Of 515 patients between 14 and 23 weeks' gestation, 493 had normal fetal karyotypes and 22 had trisomy 21. The sensitivity of an abnormal ultrasound, as defined by the presence of one or more short bones, was 63.6% and the specificity was 78.5%. According to Bayes' theorem, genetic amniocentesis may not be recommended for women less than 40 years old in the presence of normal long-bone biometry (ie, all four bones normal). CONCLUSION: Second-trimester fetal long-bone biometry is useful in detecting trisomy 21 and may be used to adjust the a priori risk of both high- and low-risk women for trisomy 21 and, therefore, the need for genetic amniocentesis

OBJECTIVE: To test the efficacy of ultrasound in detecting fetuses with trisomy 21. METHODS: From November 1, 1992, to December 31, 1995, a second-trimester genetic sonogram was offered to all women with singleton fetuses at increased risk (at least 1:274) for trisomy 21, who had either declined genetic amniocentesis or chose to have a sonogram before deciding whether to undergo an amniocentesis. In addition to standard fetal biometry, the following ultrasound markers for aneuploidy were evaluated: structural anomalies (including face, hands, and cardiac [four-chamber view and outflow tracts]), short femur, short humerus, pyelectasis, nuchal fold thickening, echogenic bowel, choroid plexus cysts, hypoplastic middle phalanx of the fifth digit, wide space between the first and second toes, and two-vessel umbilical cord. Outcome information included the results of genetic amniocentesis, if performed, or the results of postnatal pediatric assessment and follow-up. RESULTS: Five hundred seventy-three patients had a genetic sonogram between 15 and 23 weeks' gestation: 378 patients had advanced maternal age (at least 35 years), 141 had abnormal serum biochemistry, and 54 had both. The majority (495, or 86.3%) had a normal genetic sonogram (absence of abnormal ultrasound markers); 51 (9%) had one marker present, and 27 (4.7%) had two or more markers present. Outcome was obtained on 422 patients (the remaining were ongoing pregnancies or were lost to follow-up). Twelve of 14 fetuses with trisomy 21, one fetus with trisomy 13, and one fetus with triploidy had two or more abnormal ultrasound markers present; one fetus with trisomy 21 had one abnormal marker and one had a completely normal ultrasound. When one or more abnormal ultrasound markers were present, the sensitivity, specificity, and positive and negative predictive values for trisomy 21 were 92.8%, 86.7%, 19.4%, and 99.7%, respectively. When two or more abnormal ultrasound markers were present, the corresponding values were 85.7%, 96.8%, 48%, and 99.5%. In the study population, the amniocentesis rate was 12.7% overall and 17.3% in cases with known outcome. CONCLUSION: Second-trimester genetic sonogram may be a reasonable alternative for patients at increased risk for fetal trisomy 21 who wish to avoid amniocentesis. In experienced hands, this approach may result in a high detection rate of trisomy 21 (93%), with an amniocentesis rate of less than 20%