Faculty Bibliography

The relationships among the fetal biophysical profile, umbilical cord blood pH, and Apgar scores were investigated in 124 patients undergoing cesarean section before the onset of labor. Based on a standard for the diagnosis of fetal acidosis of an umbilical cord arterial pH less than 7.20, the sensitivity, specificity, and positive and negative predictive values of the fetal biophysical profile score were 90%, 96%, 82%, and 98%, respectively. When the combination of a nonreactive nonstress test and absent fetal breathing was used as the "abnormal test," the sensitivity, specificity, and positive and negative predictive values were 100%, 92%, 71%, and 100%, respectively. The efficacy of the fetal biophysical profile to indicate fetal acidosis was found to be superior to the 1- and 5-minute Apgar scores in sensitivity and positive predictive value. These data suggest that the biophysical profile is very accurate in the identification of the fetus with acidemia. The first manifestations of fetal acidosis are nonreactive nonstress testing and loss of fetal breathing; in advanced acidemia fetal movements and fetal tone are compromised. A new protocol of antepartum fetal evaluation is suggested based on individual biophysical components rather than the score alone.

Malignant melanoma is an infrequently described type of congenital neoplasm. We report a case of primary fetal malignant melanoma. A review of the literature yielded six previous cases, four of which were due to metastasis from advanced maternal disease, and two of which were fetal (primary) in origin. Recommendations are discussed for management of this rare fetal malignancy.

A protocol using daily fetal biophysical assessment was applied in 73 consecutive patients with premature rupture of the membranes and no clinical signs of infection or labor. A persistently low biophysical score (7 or less on two examinations 2 hours apart) in the presence of a nonreactive nonstress test and absence of fetal breathing was used as an indication for delivery. Measures of pregnancy outcome included the presence of amnionitis or neonatal infection. The outcome of pregnancy in this group of patients was compared with the outcomes of two historic groups: one managed conservatively (control group) and the other managed with amniocentesis on admission to the hospital (amniocentesis group). Infection outcome, maternal as well as neonatal, and low 5-minute Apgar scores were significantly less in the study than in the control group. The frequency of neonatal sepsis was significantly less in the study than in the amniocentesis group. These data suggest that management of premature rupture of the membranes with daily fetal biophysical profiles improves pregnancy outcome by reducing the incidence of maternal and neonatal infection.

Most current sonographic techniques for estimating fetal weight involve measurements of the head, abdomen, and femur length both alone and in combination. The value of the fetal thigh circumference measurement in addition to the head, abdominal, and femur length measurements has not been investigated previously. Eighty-nine patients were scanned within 72 hours of delivery, and the following ultrasonic fetal parameters were obtained in all fetuses: biparietal diameter, head circumference, abdominal circumference, femur length, and thigh circumference. With multiple stepwise regression analysis, the best-fit formulas were developed with one, two, three, four, and five parameters, respectively. The best results were obtained by combining measurements of all five parameters: biparietal diameter, head circumference, abdominal circumference, femur length, and thigh circumference. The mean error of this formula was 6%, the mean deviation 0.3%, and the SD 7.8%. These data suggest that the addition of thigh circumference to measurements of the head, abdomen, and femur length improves the accuracy of fetal weight estimates.

In a prospective study of 124 patients undergoing cesarean section before the onset of labor, the fetal biophysical profile was found to have a significant relationship with umbilical cord blood pH (artery and vein). Using cord arterial pH less than 7.20 as a standard for the diagnosis of fetal acidosis, the sensitivity, specificity, and positive and negative predictive values of the fetal biophysical profile score were 90, 96, 82, and 98%, respectively. When the combination of nonreactive nonstress test and absent fetal breathing was used as the "abnormal test," the sensitivity, specificity, and positive and negative predictive values were 100, 92, 71, and 100%, respectively. The first manifestations of fetal acidosis are nonreactive nonstress testing and loss of fetal breathing; in advanced acidemia, fetal movements and fetal tone are compromised. A protocol of antepartum fetal evaluation is suggested based upon the individual biophysical components rather than the score alone.

A retrospective study of 298 patients with preterm premature rupture of the membranes managed expectantly during a 3-year period investigated the association between preterm premature rupture of the membranes and abruptio placentae. Expectant management was associated with the development of abruptio placentae in 19 of these 298 patients (6.3%). The prevalence of abruptio placentae in the entire population during the same 3-year period was 2.7%, whereas in patients without preterm premature rupture of the membranes it was 2%. None of the patients developed clinical or laboratory evidence of disseminated intravascular coagulation and no infection (maternal or neonatal) was noted among the patients who had abruptio placentae. Patients with preterm premature rupture of the membranes and severe oligohydramnios (largest pocket less than 1 cm) seem to be at particular risk for developing this complication. These data suggest that abruptio placentae should be considered as one of the possible risks of expectant management in preterm premature rupture of the membranes.

Ehlers-Danlos syndrome type IV (EDS IV) is a rare but serious disorder of connective tissue that is characterized by the abnormal production or secretion of type III collagen. Experience with pregnant patients exhibiting this syndrome is limited. This report describes the successful management of a pregnancy in a woman with EDS IV that included activity restriction and complete bed rest after 32 weeks, use of 1-desamino-8-D-arginine vasopressin (DDAVP) before delivery to improve coagulation, and cesarean section before the onset of labor. The possibility of prenatal diagnosis based on genetic linkage studies also is discussed.

The components of the fetal biophysical profile of pregnancies with grade III placentas and good outcome were retrospectively analyzed and compared to the fetal biophysical components of pregnancies with grade 0 to II placentas. The results of the present study suggest that the dynamic components of the fetal biophysical profile (nonstress test, fetal breathing movements, fetal movements, fetal tone) are not altered in the presence of a grade III placenta and good pregnancy outcome; however, a greater incidence of reduced amniotic fluid volume was found in the presence of grade III placenta. The clinical significance of grade III placenta is discussed.

With the advent of improved ultrasound imaging, it is now possible to make an intrauterine diagnosis of many fetal anomalies. The key to an accurate antenatal diagnosis is careful scanning of the fetus and knowledge of the abnormalities that may be associated with a particular anomaly. In the presence of fetal anomalies known to be associated with increased frequency of chromosome abnormalities, fetal karyotyping is indicated, using either amniocentesis or fetal blood sampling, depending upon the urgency of the diagnosis. Fetal echocardiography is mandatory when the ultrasonically detected fetal anomaly is one that is known to be associated frequently with cardiac disease. Based on the antenatal findings, the parents should receive appropriate genetic and perinatal counseling. The management plan should always take into consideration the parents' wishes. Management plans for the most common ultrasonically detected fetal anomalies are presented, based upon review of the literature and authors' experience.

A case of congenital midline porencephaly, including the prenatal sonographic findings, is presented. A review of the literature showed that six cases of congenital midline porencephaly have been reported, though none had sonographic evaluation in the prepartum period. The prenatal sonographic diagnosis of this rare disorder is discussed along with the clinical and pathologic findings and outcome of all reported cases.