Faculty Bibliography

OBJECTIVE: To construct a management guide for preterm pregnancies complicated by severely abnormal umbilical artery Doppler velocimetry. METHODS: A retrospective chart review was conducted on all cases of absent or reversed end-diastolic flow umbilical artery Doppler velocimetry identified through an ultrasound data base. Maternal and perinatal outcome variables were retrospectively reviewed and analyzed using both parametric and nonparametric statistical techniques. Seventy-one cases were identified over a 5-year period. After excluding multiple gestations, anomalous fetuses, and two cases that were terminated before 24 weeks' gestation, 56 singleton gestations remained for analysis. RESULTS: Among the 56 subjects, there were 45 survivors and 11 deaths (five fetal and six neonatal deaths). Nonsurvivors had a significantly lower gestational age at diagnosis and delivery. Nonsurviving live-born neonates had lower Apgar scores and were significantly smaller; however, there were no differences in proportion or severity of fetal growth restriction in survivors and nonsurvivors. There were no differences in last biophysical profile before delivery or interval from diagnosis of reversed end-diastolic flow to delivery. Predictors of nonsurvival were the presence of reversed end-diastolic flow and oligohydramnios. Perinatal mortality for reversed end-diastolic flow was 333/1000 and 94/1000 for absent end-diastolic flow. Risk for perinatal death was highly gestational age dependent. For delivery at less than 26 weeks, survival was one of four; at 26-27.9 weeks, survival was seven of 12; and at 28 weeks or greater, survival was 37 of 40. CONCLUSION: Whereas severely abnormal umbilical artery blood flow poses significant risk for pregnancy, perinatal mortality is dominated by gestational age at diagnosis and delivery. This may reflect the severity of the disease or the low survival of very immature gestations. Interventions on behalf of the fetus at very early gestational ages should be undertaken with caution.

OBJECTIVE: To study fetuses who had the sonographic diagnosis of hemivertebrae made in utero (excluding open neural tube defects) and to determine the incidence of associated anomalies, karyotypes, and neonatal outcome. METHODS: Twenty-seven fetuses with sonographically detected vertebral abnormalities (excluding neural tube defects) and postnatal follow-up were included in the study. Associated structural defects and karyotypic anomalies were tabulated. The outcome for fetuses with isolated vertebral abnormalities on prenatal sonogram was compared with that of fetuses with associated anomalies. RESULTS: Eleven of 27 fetuses had hemivertebrae as the only sonographic anomaly. Nine of the 11 were live-born with a good outcome; one patient elected pregnancy termination, and one fetus died of sepsis after premature rupture of the membranes. Sixteen fetuses had other anomalies including cardiac, intestinal, renal, intracranial, and limb anomalies. Seven of these 16 had Potter syndrome, two of whom also had sacral agenesis. Only five of those with additional anomalies survived; five died and six pregnancies were electively terminated. Because four of the six aborted fetuses had Potter syndrome (renal dysgenesis), a lethal malformation, a total of at least nine of the 16 fetuses with other anomalies would not have survived. All seven fetuses with severe oligohydramnios had lethal anomalies. Eighteen fetuses underwent karyotyping (including all those with isolated vertebral anomalies), and all had normal karyotypes. CONCLUSION: Our study suggests that sonographically diagnosed, isolated fetal vertebral anomalies carry a good prognosis and the likelihood of a normal karyotype. The presence of associated anomalies reduces the survival to 50%, and when accompanied by significant oligohydramnios, the mortality is 100%.

OBJECTIVES: By means of hospital-based data over 9 years we sought to evaluate the clinical indications and incidence of emergency peripartum hysterectomy by demographic characteristics and reproductive history. STUDY DESIGN: From the obstetric records of all deliveries at Brigham and Women's Hospital between Oct. 1, 1983, and July 31, 1991, we identified all women undergoing emergency peripartum hysterectomy, calculated crude and adjusted incidence rates, conducted statistical tests of linear trends and heterogeneity, and observed the clinical indications preceding the onset of this procedure. RESULTS: There were 117 cases of peripartum gravid hysterectomy identified during this period, for an overall annual incidence of 1.55 per 1000 deliveries. The rate increased with increasing parity and was significantly influenced by placenta previa and a history of cesarean section. The incidence by parity increased from one in 143 deliveries in nulliparous women with placenta previa to one in four deliveries in multiparous women with four or more deliveries with placenta previa. Likewise, the incidence increased from one in 143 deliveries in women with one prior live birth and a prior cesarean section to one in 14 deliveries in multiparous women with four or more deliveries with a history of a prior cesarean section. Both these trends were highly significant (p < 0.001). Abnormal adherent placentation was the most common cause preceding gravid hysterectomy (64%, p < 0.001), with uterine atony accounting for 21%. Although no maternal deaths occurred, maternal morbidity remained high, including postoperative infection in 58 (50%), intraoperative urologic injury in 10 patients (9%), and need for transfusion in 102 patients (87%). CONCLUSIONS: The data identify abnormal adherent placentation as the primary cause for gravid hysterectomy. The data also illustrate how the incidence of emergency peripartum hysterectomy increases significantly with increasing parity, especially when influenced by a current placenta previa or a prior cesarean section. Maternal morbidity remained high although no maternal deaths occurred