Faculty Bibliography

OBJECTIVE:To determine if a correlation exists between the level of maternal serum alpha-fetoprotein (MSAFP) elevation and the rate of adverse pregnancy outcome, to examine the timing of pregnancies ending in fetal or neonatal death, and to develop a protocol for antepartum surveillance in an effort to prevent these adverse outcomes. STUDY DESIGN/METHODS:Singleton pregnancies with a single second-trimester elevated MSAFP > or = 2.0 multiples of the median (MoM) were eligible if a targeted ultrasound evaluation (< 24 weeks) was in agreement with the dates and no fetoplacental anomaly was detected. Three groups were established based on the second-trimester MSAFP elevation: 2.0-2.49, 2.5-2.99 and > or = 3.0 MoM. RESULTS:Among the 383 patients enrolled, delivery data were available on 333 infants. Stratified by MSAFP elevations of 2.0-2.49, 2.5-2.99 and > or = 3.0 MoM, the rates of adverse pregnancy outcome were: (1) preterm birth: 14.3%, 15.6%, 20.3%; (2) small for gestational age at birth: 7.4%, 11.1%, 22.2%; and (3) perinatal deaths (neonatal and fetal): 2.6%, 3.3%, 5.6%. Seven pregnancy losses (three neonatal and four fetal deaths) occurred prior to 28 weeks. Of these seven, six fetuses exhibited intrauterine growth retardation by 23-26 weeks' gestation, and five of six were associated with MSAFP levels > or = 2.5 MoM. Four losses (two neonatal and two fetal deaths) occurred after 28 weeks. Of these, three involved structurally normal infants with normal growth who died after 34 weeks. All three of these pregnancies exhibited MSAFP elevations < 2.5 MoM. CONCLUSION/CONCLUSIONS:In pregnancies with an unexplained elevated second-trimester MSAFP, the rate of adverse pregnancy outcomes is increased with higher elevations. Any proposed program to improve pregnancy outcome in patients with unexplained MSAFP elevations must include efforts aimed at preventing preterm delivery, repeat ultrasound at 24-26 weeks to rule out early-onset intrauterine growth retardation in pregnancies with elevations > or = 2.5 MoM and fetal biophysical monitoring, even in normally grown fetuses, instituted at 32 weeks to detect fetuses at risk for intrauterine death.

In the United States, first-and second-trimester ultrasonography is most commonly used for gestational dating, detection of fetal aneuploidy, identification of early fetal intrauterine growth restriction (IUGR), and assessment for cervical incompetence. Crown-rump length (CRL) between 7 and 12 weeks is the most accurate parameter for first-trimester dating. In the second trimester, the biparietal diameter, head circumference, transverse cerebellar diameter (TCD), abdominal circumference, femur length, and other long bones, such as tibia and humerus, are useful. The TCD appears to be particularly useful because of its relative sparing in IUGR. Ultrasound can aid in the detection of fetal aneuploidy by identifying structural anomalies or abnormal fetal biometry in the first and second trimester. Numerous structural abnormalities are suggestive of aneuploidy. Cystic hygroma and nuchal translucency appear to be most significant first-trimester markers for fetal aneuploidy. Second-trimester estimated fetal weight (FFW) curves have been developed and are useful in the early detection of IUGR. Second-trimester FFW curves are useful for the detection of trisomy 18 (sensitivity 60%) but not for trisomy 21 (sensitivity 8-12%). Fetal biometry of long bones is also useful in identifying fetuses at risk for aneuploidy. Identification of a second-trimester fetus with either humerus or femur shorter than expected places the fetus at risk for aneuploidy. The sensitivity of short long bone in detection of fetal aneuploidy is approximately 30%, with false positive rates < 5%. Nuchal fold thickness > 6 mm in the second trimester is also used for identifying aneuploid fetuses. The overall sensitivity for the detection of Down's syndrome in fetuses with increased nuchal fold thickness is approximately 34% and the false positive rate is 1.5%. We have developed a model by using an ultrasound examination to adjust the mid-trimester risk for trisomy 21 by combining maternal age or triple screen risk assessment (unconjugated estriol, alpha fetoprotein, and human chorionic gonadotropin) and ultrasound. Using this model, the risk for Down's syndrome is found to be increased with identification of abnormal biometry or anomalies, or decreased with a normal genetic ultrasound examination. Another important application is the use of abdominal and transvaginal ultrasound in the second trimester in pregnancies at risk for premature cervical dilatation, premature delivery, and cervical incompetence. We have found transfundal pressure to be useful in the diagnosis of otherwise clinically inapparent premature cervical dilatation and cervical incompetence.

OBJECTIVE: To assess the incidence of placental basal plate myometrial fibers in preterm and term gestations and correlate this finding with clinical observations and placental histopathology. METHODS: Placentas from 457 singleton births before 32 weeks' gestation and 108 uncomplicated singleton births after 37 weeks' gestation were examined histopathologically. Pregnancies complicated by maternal chronic hypertension, diabetes mellitus, coagulopathy, placenta previa, stillbirth, multiple fetuses, and fetal congenital anomalies were excluded from both groups. In the preterm group, 158 patients had preterm labor with intact membranes, 192 had preterm premature rupture of membranes (PROM), 31 had placental abruption without hypertension, and 76 had preeclampsia. Histopathology detected the presence of placental basal plate myometrial fibers, placental vascular lesions, and villous damage related to vascular insufficiency. RESULTS: Forty-four of 457 (9.6%) of preterm placentas had basal plate myometrial fibers, compared with one of 108 (0.9%) term controls (P < .001). Uteroplacental vessels with abnormal physiologic changes were more frequent and placental weights were lower in cases with basal plate myometrial fibers (P < .003 and P < .03, respectively). No other uteroplacental vascular lesions were related to basal plate myometrial fibers. The frequency of placental basal plate myometrial fibers was nine of 76 (12%) in cases complicated by preeclampsia, 21 of 192 (11%) cases of PROM, nine of 158 (5.7%) cases of preterm labor, and four of 31 (13%) cases of placental abruption without hypertension; these frequencies were not significantly different, and there was no significant relationship to gravidity, parity, mode of delivery, or birth weight. CONCLUSION: Placental basal plate myometrial fibers occur in ten times as many preterm births as term births. This finding is associated with both abnormal uteroplacental physiologic changes and decreased placental weight, and may explain the increased incidence of abnormalities of the third stage of labor associated with preterm delivery

Ultrasonography has increasingly become essential in the practice of obstetrics and gynecology. Its antenatal use is well described in the literature and is a continuing subject of study. However, the use of ultrasonography in the labor and delivery suite has not been the subject of many articles. The purpose of this chapter is to review the pertinent literature along with the experience of the authors in order to define the role of ultrasonography in the Labor and Delivery Suite

We report the prenatal diagnosis of mid shaft hypospadias and describe the sonographic features of fetal hypospadias including an abnormal urethral canal, ventral curvature of the distal penis, extension of the penile glans beyond the prepuce, and fetal micturation in a plane perpendicular to the penile shaft. An accurate family history is an essential part of the evaluation of the milder degrees of fetal hypospadias

The objective of this study was to determine the degree of documented compliance of community-based ultrasound reports with suggested standards/guidelines for basic ultrasound examinations as published by the American College of Obstetricians and Gynecologists (ACOG) and the American Institute of Ultrasound in Medicine (AIUM). First trimester reports from obstetric offices (n = 20) had complete compliance with ACOG guidelines in 35% and AIUM standards in 15% of the cases (p = NS). Radiological reports (n = 26) had complete compliance with ACOG guidelines in 11.5% and AIUM standards in 3.9% of the cases (p = NS). None of the second/third trimester reports from either the obstetrical offices (n = 35) or from radiological facilities (n = 94) had complete compliance with either ACOG or AIUM standards/guidelines. Ultrasound reports generated by community-based obstetricians and radiologists from our referral sources demonstrate significant omissions in documentation of components suggested by AIUM and ACOG for minimum standards of basic ultrasound examinations.

The objective of this study was to determine whether vacuum extraction is associated with umbilical cord blood acid-base changes when used electively or in the presence of suspected fetal distress. Data from 1,428 patients from a previously published randomized trial of intrapartum electronic fetal heart rate monitoring versus intermittent auscultation were analyzed to identify differences in umbilical cord blood acid-base measurements associated with the elective use of vacuum extraction (patients with duration of second stage of labor 60 min or less) and also in the presence of suspected fetal distress during the second stage of labor. When used electively, vacuum extraction was associated with lower pH (in both umbilical cord artery and vein), lower venous base excess, and higher venous carbon dioxide tension (PCO2), as compared to normal spontaneous vaginal delivery. After correcting for duration of second stage of labor, elective vacuum delivery was significantly associated only with a decrease in cord venous pH and increase in venous PCO2. However, these cord blood acid-base changes were not accompanied by any differences in perinatal morbidity and mortality or in the number of neonates born with acidemia (cord arterial pH < 7.15 or < 7.10). In cases of suspected fetal distress, the use of vacuum extraction was not associated with any detectable cord blood acid-base changes as compared to normal spontaneous vaginal delivery. These data support the continued use of vacuum extraction, especially in cases of suspected fetal distress during the second stage of labor

Puerperal psychosis occurs after delivery in 1-2/1,000 births. It usually presents after delivery, however, it also may present in the antepartum period. We report the third case which presented prior to delivery without a preceding history of maternal puerperal psychosis and the first which presented with catatonia and symptoms of eclampsia. Although uncommon, the first presentation of psychosis during pregnancy should be considered part of the differential diagnosis in pregnant patients presenting with altered mental status after organic causes are excluded.