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Houlihan C, Poon LCY, Ciarlo M, Kim E, Guzman ER, Nicolaides KH. Cervical cerclage for preterm birth prevention in twin gestation with short cervix: a retrospective cohort study. Ultrasound Obstet Gynecol 2016; 48:752-756. [PMID: 26990136 DOI: 10.1002/uog.15918] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Revised: 02/20/2016] [Accepted: 03/09/2016] [Indexed: 06/05/2023]
Abstract
OBJECTIVE To determine if cervical cerclage reduces the rate of spontaneous early preterm birth in cases of dichorionic-diamniotic (DCDA) twin gestation with an ultrasound-detected short cervix. METHODS This was a retrospective cohort study of 40 consecutive DCDA twin gestations at Saint Peter's University Hospital from November 2006 to November 2014 in which cervical cerclage was performed for an ultrasound-determined cervical length of 1-24 mm at 16-24 weeks' gestation. The cases were matched with 40 controls without cerclage for cervical length and gestational age at cervical assessment. The primary outcome measure was spontaneous birth < 32 weeks. RESULTS There was no difference between the two groups in maternal age, body mass index (BMI), cigarette smoking, use of in-vitro fertilization (IVF), parity and prior spontaneous preterm birth. There were more Caucasian women among the controls compared with cases. In the cases, compared with controls, spontaneous delivery < 32 weeks was significantly less frequent (20.0% vs 50.0%; relative risk, 0.40 (95% CI, 0.20-0.80)). In the prediction of spontaneous delivery < 32 weeks, logistic regression analysis demonstrated that the risk was reduced with the insertion of cervical cerclage (odds ratio, 0.22 (95% CI, 0.058-0.835); P = 0.026), corrected for maternal age, BMI, racial origin, cigarette smoking, IVF, parity and previous preterm birth. CONCLUSION In DCDA twin gestation with a short cervix, treatment with cervical cerclage may reduce the rate of early preterm birth. The findings suggest the need for adequate randomized controlled trials on cerclage in twin gestations with a short cervix. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- C Houlihan
- Department of Obstetrics and Gynecology, Saint Peter's University Hospital (SPUH), New Brunswick, NJ, USA
| | - L C Y Poon
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
| | - M Ciarlo
- Department of Obstetrics and Gynecology, Saint Peter's University Hospital (SPUH), New Brunswick, NJ, USA
| | - E Kim
- Department of Obstetrics and Gynecology, Saint Peter's University Hospital (SPUH), New Brunswick, NJ, USA
| | - E R Guzman
- Department of Obstetrics and Gynecology, Saint Peter's University Hospital (SPUH), New Brunswick, NJ, USA
| | - K H Nicolaides
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
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Szychowski JM, Owen J, Hankins G, Iams JD, Sheffield JS, Perez-Delboy A, Berghella V, Wing DA, Guzman ER. Can the optimal cervical length for placing ultrasound-indicated cerclage be identified? Ultrasound Obstet Gynecol 2016; 48:43-47. [PMID: 26277877 PMCID: PMC6918708 DOI: 10.1002/uog.15674] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2015] [Revised: 08/06/2015] [Accepted: 08/10/2015] [Indexed: 06/04/2023]
Abstract
OBJECTIVE To assess a continuum of cervical length (CL) cut-offs for the efficacy of ultrasound-indicated cerclage in women with previous spontaneous preterm birth (PTB). METHODS This was a planned secondary analysis of a multicenter randomized clinical trial of ultrasound-indicated cerclage for the prevention of PTB in high-risk women. The efficacy of cerclage for preventing recurrent PTB < 35, < 32 and < 24 weeks' gestation was assessed using multivariable logistic regression analysis. Odds ratios (ORs) and CIs were estimated for a range of CL cut-offs using bootstrap regression. The 2.5(th) and 97.5(th) percentiles of bootstrapped ORs determined the CIs. Results were illustrated using smoothed curves superimposed on estimated ORs by CL cut-off. RESULTS Of 301 women with a CL < 25 mm, 142 underwent ultrasound-indicated cerclage and 159 did not have cerclage placement. The few cases with CL < 10 mm limited the evaluation to CL cut-offs between < 10 mm and < 25 mm. For PTB < 35 weeks, ORs in women with a cerclage and CL < 25 mm were statistically significantly lower than in those without cerclage, and efficacy was maintained at smaller CL cut-offs. Results were similar for PTB < 32 weeks. For PTB < 24 weeks, results differed, with ORs increasing toward unity (no benefit), with wide CIs, for CL cut-offs between < 10 mm and < 15 mm, attributed to the small number of births < 24 weeks. CONCLUSIONS The efficacy of ultrasound-indicated cerclage in women with previous spontaneous PTB varies by action point CL cut-off and by PTB gestational age of interest. Cerclage significantly reduces the risk of PTB < 35 and < 32 weeks, at CL cut-offs between < 10 mm and < 25 mm, with the greatest reduction at shorter CL, affirming that women with prior spontaneous PTB and a short CL are appropriate candidates for ultrasound-indicated cerclage. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- J M Szychowski
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - J Owen
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - G Hankins
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, TX, USA
| | - J D Iams
- Department of Obstetrics and Gynecology, The Ohio State University Medical Center, Columbus, OH, USA
| | - J S Sheffield
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - A Perez-Delboy
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - V Berghella
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia, PA, USA
| | - D A Wing
- Department of Obstetrics and Gynecology, University of California, Irvine, Orange, CA, USA
| | - E R Guzman
- Department of Obstetrics and Gynecology, Saint Peter's University Hospital, New Brunswick, NJ, USA
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Farinelli CK, Wing DA, Szychowski JM, Owen J, Hankins G, Iams JD, Sheffield JS, Perez-Delboy A, Berghella V, Guzman ER. Association between body mass index and pregnancy outcome in a randomized trial of cerclage for short cervix. Ultrasound Obstet Gynecol 2012; 40:669-73. [PMID: 23192994 PMCID: PMC6918710 DOI: 10.1002/uog.11170] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/21/2012] [Indexed: 06/05/2023]
Abstract
OBJECTIVE To evaluate whether increasing body mass index (BMI) alters the efficacy of ultrasound-directed cerclage in women with a history of preterm birth. METHODS This was a planned secondary analysis of a multicenter trial in which women with a singleton gestation and prior spontaneous preterm birth (17 to 33 + 6 weeks' gestation) were screened for a short cervix by serial transvaginal ultrasound evaluations between 16 and 22 + 6 weeks. Women with a short cervix (cervical length < 25 mm) were randomly assigned to cerclage or not. Linear and logistic regression were used to assess the relationship between BMI and continuous and categorical variables, respectively. RESULTS Overall, in the screened women (n = 986), BMI was not associated with cervical length (P = 0.68), gestational age at delivery (P = 0.12) or birth at < 35 weeks (P = 0.68). For the cerclage group (n = 148), BMI had no significant effect. For the no-cerclage group (n = 153), BMI was associated with a decrease in gestational age at delivery, with an estimated slope of - 0.14 weeks per kg/m(2) (P = 0.03; including adjustment for cervical length). This result was driven primarily by several women with BMI > 47 kg/m(2) . CONCLUSION In women at high risk for recurrent preterm birth, BMI was not associated with cervical length or gestational age at birth. BMI did not appear to adversely affect ultrasound-indicated cerclage.
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Affiliation(s)
- C K Farinelli
- Department of Obstetrics and Gynecology, University of California, Irvine, CA 92869, USA.
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Szychowski JM, Owen J, Hankins G, Iams J, Sheffield J, Perez-Delboy A, Berghella V, Wing DA, Guzman ER. Timing of mid-trimester cervical length shortening in high-risk women. Ultrasound Obstet Gynecol 2009; 33:70-75. [PMID: 19072745 PMCID: PMC3065937 DOI: 10.1002/uog.6283] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
OBJECTIVE To examine the natural history of cervical length shortening in women who had experienced at least one prior spontaneous preterm birth at between 17+0 and 33+6 weeks' gestation. METHODS This was an analysis of prerandomization data from the multicenter Vaginal Ultrasound Cerclage Trial. Serial cervical length was measured by transvaginal sonography in 1014 high-risk women at 16+0 to 22+6 weeks. We performed survival analyses in which the outcome was cervical length shortening<25 mm and data were censored if this did not occur before 22+6 weeks' gestation. The incidence of cervical length shortening and the time to shortening were compared for women whose earliest prior preterm birth was in the mid-trimester, defined as <24 weeks, vs. those at weeks 24-33. Similar comparisons were performed based on each patient's most recent birth history. RESULTS Time to cervical length shortening by survival analysis was significantly shorter (hazard ratio (HR)=2.2, P<0.0001) and the relative risk (RR) of shortening significantly higher (RR=1.8, P<0.0001) for women whose earliest prior spontaneous preterm birth was at <24 weeks. A larger effect was observed for women whose most recent birth was at <24 weeks (HR=2.8, P<0.0001; RR=2.1, P<0.0001). The observed hazard ratios remained significant after adjusting for confounders in a multivariable Cox proportional hazards model. CONCLUSION Women with a prior spontaneous preterm birth at <24 weeks are at a higher risk of cervical shortening, and do so at a higher rate and at an earlier gestational age, than do women with a later preterm birth history.
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Affiliation(s)
- J M Szychowski
- University of Alabama at Birmingham, Department of Biostatistics, Birmingham, Alabama 35249-7333, USA
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Guzman ER, Walters C, Ananth CV, O'Reilly-Green C, Benito CW, Palermo A, Vintzileos AM. A comparison of sonographic cervical parameters in predicting spontaneous preterm birth in high-risk singleton gestations. Ultrasound Obstet Gynecol 2001; 18:204-210. [PMID: 11555447 DOI: 10.1046/j.0960-7692.2001.00526.x] [Citation(s) in RCA: 76] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
OBJECTIVES To assess the role of cervical sonography and to compare various sonographic cervical parameters in their ability to predict spontaneous preterm birth in high-risk singleton gestations. DESIGN A prospective cohort of 469 high-risk gestations were longitudinally evaluated between 15 and 24 weeks' gestation on 1265 occasions with transvaginal cervical sonography and transfundal pressure. The cervical parameters obtained were funnel width and length, cervical length, percent funneling and cervical index. The information obtained was used for patient management. Restriction of physical activities was initiated at cervical lengths of < or = 2.5 cm with cerclage as an option for cervical lengths of < or = 2.0 cm. RESULTS Receiver operating characteristic curve analyses showed that a cervical length of < or = 2.5 cm between 15 and 24 weeks' gestation was equal to the other sonographic cervical parameters in its ability to predict spontaneous preterm birth. The sensitivities for delivery at < 28, < 30, < 32 and < 34 weeks' gestation were 94%, 91%, 83% and 76%, respectively, while the negative predictive values were 99%, 99%, 98% and 96%, respectively. The placement of a cerclage did not influence the positive and negative predictive values. In comparison to women with other risk factors, cervical length was best in the prediction of preterm birth in women with a prior mid-trimester loss; an optimal cut-off of < or = 1.5 cm had sensitivities for delivery at < 28, < 30, < 32 and < 34 weeks' gestation of 100%, 100% 92% and 81%, respectively. The rate of preterm delivery at < 34 weeks' gestation increased dramatically when the cervical length was < or = 1.5 cm. Cervical length was the only independent variable that entered the logistic regression model for the prediction of preterm delivery at < 34 weeks' gestation. CONCLUSIONS In high-risk singleton gestations a cervical length of < or = 2.5 cm was equal to other sonographic cervical parameters in its ability to predict spontaneous preterm birth and was better for the prediction of earlier forms of prematurity (at < 28 and < 30 weeks) than later forms (at < 32 and < 34 weeks). The optimal cervical lengths and their performance for predicting prematurity may be influenced by obstetric risk factors.
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Affiliation(s)
- E R Guzman
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, Saint Peter's University Hospital, New Brunswick, New Jersey, USA.
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Guzman ER, Ananth CV. Cervical length and spontaneous prematurity: laying the foundation for future interventional randomized trials for the short cervix. Ultrasound Obstet Gynecol 2001; 18:195-199. [PMID: 11555445 DOI: 10.1046/j.0960-7692.2001.525.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Affiliation(s)
- E R Guzman
- Division of Maternal-Fetal Medicine, Gynecology and Reproductive Sciences, Department of Obstetrics, Gynecology and Reproductive Sciences, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
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Smulian JC, Ananth CV, Vintzileos AM, Guzman ER. Revisiting sonographic abdominal circumference measurements: a comparison of outer centiles with established nomograms. Ultrasound Obstet Gynecol 2001; 18:237-243. [PMID: 11555453 DOI: 10.1046/j.0960-7692.2001.473.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
OBJECTIVE To construct an institution-specific nomogram of fetal abdominal circumference measurements and determine whether previously published nomograms correctly categorize our population's outer centiles. DESIGN Using cross-sectional data from a database of sonographic circumference measurements, a nomogram for abdominal circumference measurements was created by modeling the mean and standard deviation separately. The adequacy of the nomogram was confirmed by assessing the normal distribution of data, verifying goodness-of-fit, and checking residuals. Outer centiles were compared with those from other published nomograms. RESULTS The new nomogram for fetal abdominal circumference measurements from 10 070 fetuses provided sufficient data to derive values for the 5th, 10th, 50th, 90th and 95th centiles based on gestational age. Comparisons with other published nomograms indicated that the false-negative rates for classifying our population as < 10th centile or > 90th centile ranged from 11.3% to 90.5% and from 0 to 66.4%, respectively. CONCLUSION Institution-specific nomograms of fetal abdominal circumference measurements are important to avoid incorrect categorization of outer centiles.
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Affiliation(s)
- J C Smulian
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Medicine and Dentistry of New Jersey--Robert Wood Johnson Medical School/Saint Peter's University Hospital, New Brunswick, New Jersey 08903-0591, USA.
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Kinzler WL, Smulian JC, McLean DA, Guzman ER, Vintzileos AM. Outcome of prenatally diagnosed mild unilateral cerebral ventriculomegaly. J Ultrasound Med 2001; 20:257-262. [PMID: 11270530 DOI: 10.7863/jum.2001.20.3.257] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
The objective of this study was to determine the frequency of prenatally diagnosed unilateral cerebral ventriculomegaly and also to assess neonatal outcome in infants with this prenatal diagnosis. A computerized ultrasonography database identified fetuses with isolated and nonisolated unilateral cerebral ventriculomegaly from October 1994 to June 1999. The Denver II Developmental Screening Test was used to assess developmental skills. Unilateral cerebral ventriculomegaly was diagnosed in 15 of 21,172 (1 per 1,411) pregnancies. The width of the enlarged lateral ventricle ranged from 1.0 to 1.9 cm. In 10 (67%) of 15 cases unilateral cerebral ventriculomegaly was an isolated finding. Eight of the 14 infants who were born at 36 weeks' gestation or later had postnatal cranial imaging, and ventricular asymmetry was confirmed in 5 (63%). One infant with an arachnoid cyst and cerebral palsy died at 2 years of age. The remaining 11 infants in whom developmental milestones were assessed had age-appropriate skills. Unilateral fetal ventriculomegaly is usually an isolated finding and when isolated has little measurable effect on developmental outcome.
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Affiliation(s)
- W L Kinzler
- Division of Maternal Fetal Medicine, University of Medicine and Dentistry of New Jersey--Robert Wood Johnson Medical School/Saint Peter's University Hospital, New Brunswick, USA
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Guzman ER, Walters C, O'reilly-Green C, Kinzler WL, Waldron R, Nigam J, Vintzileos AM. Use of cervical ultrasonography in prediction of spontaneous preterm birth in twin gestations. Am J Obstet Gynecol 2000; 183:1103-7. [PMID: 11084549 DOI: 10.1067/mob.2000.108896] [Citation(s) in RCA: 86] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE This study was undertaken to compare various ultrasonographic cervical parameters with respect to ability to predict spontaneous preterm birth in twin gestations. STUDY DESIGN This prospective study involved 131 women carrying twins who were longitudinally evaluated on 524 occasions between 15 and 28 weeks' gestation with transvaginal cervical ultrasonography and transfundal pressure. The following cervical parameters were obtained: funnel width and length, cervical length, percentage of funneling, and cervical index. Receiver operating characteristic curve analysis was used to determine the ultrasonographic cervical parameter evaluated at 15 to 20 weeks' gestation, 21 to 24 weeks' gestation, and 25 to 28 weeks' gestation that were best for prediction of spontaneous preterm birth at <28 weeks' gestation, <30 weeks' gestation, <32 weeks' gestation, and <34 weeks' gestation. RESULTS The median gestational age at delivery was 36 weeks' gestation (range, 21-41 weeks' gestation). Receiver operating characteristic curve analysis indicted that a cervical length of < or =2.0 cm, regardless of gestational age category at cervical measurement, was at least as good as other ultrasonographic cervical parameters at predicting spontaneous preterm birth. Between 15 and 20 weeks' gestation a cervical length cutoff value of < or =2.0 cm had specificities of 97%, 98%, 99%, and 100% and negative predictive values of 99%, 98%, 95%, and 89% for delivery at <28, <30, <32, and <34 weeks' gestation, respectively. The positive predictive values for delivery at <32 and <34 weeks' gestation were 80% and 100%, respectively. Between 21 and 24 weeks' gestation a cervical length of < or =2.0 cm had specificities of 84%, 84%, 85%, and 86% and negative predictive values of 99%, 99%, 94%, and 87% for delivery at <28, <30, <32, and <34 weeks' gestation, respectively. Between 25 and 28 weeks' gestation cervical length had excellent negative predictive values of 99%, 98%, 95%, and 93% for delivery at <28, <30, <32, and <34 weeks' gestation, respectively. CONCLUSIONS In twin gestations a cervical length of < or =2.0 cm measured between 15 and 28 weeks' gestation was at least as good as other ultrasonographic cervical parameters at predicting spontaneous preterm birth. The high specificities indicate that cervical length was better at predicting the absence than the presence of various degrees of spontaneous prematurity.
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Affiliation(s)
- E R Guzman
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, Saint Peter's University Hospital, NJ 08903-0591, USA
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Guzman ER, Walters C, O'reilly-Green C, Meirowitz NB, Gipson K, Nigam J, Vintzileos AM. Use of cervical ultrasonography in prediction of spontaneous preterm birth in triplet gestations. Am J Obstet Gynecol 2000; 183:1108-13. [PMID: 11084550 DOI: 10.1067/mob.2000.108875] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The aim of this study was to assess the role of cervical ultrasonography in the prediction of spontaneous preterm birth in triplet gestations and to compare various ultrasonographic cervical parameters with respect to predictive ability. STUDY DESIGN This prospective cohort study included 51 triplet gestations longitudinally evaluated between 15 and 28 weeks' gestation on 274 occasions with transvaginal cervical ultrasonography and transfundal pressure. The cervical parameters obtained were funnel width and length, cervical length, percentage of funneling, and cervical index. RESULTS Receiver operating characteristic curve analyses showed that cervical lengths of < or =2.5 cm and < or =2.0 cm between 15 and 24 weeks' gestation and between 25 and 28 weeks' gestation, respectively, were at least as good as other ultrasonographic cervical parameters for the prediction of spontaneous preterm birth. A cervical length of < or =2.5 cm between 15 and 20 weeks' gestation had both a specificity and a positive predictive value of 100% for delivery at <28 weeks' gestation, and the sensitivities and negative predictive values ranged from 25% to 50% and from 72% to 91%, respectively, for deliveries at <28, <30, and <32 weeks' gestation. A cervical length of < or =2.5 cm between 21 and 24 weeks' gestation had an 86% sensitivity for prediction of spontaneous delivery at <28 weeks' gestation. A cervical length of < or =2.0 cm between 25 and 28 weeks' gestation had both a sensitivity and a negative predictive value of 100% for delivery at both <28 and <30 weeks' gestation. CONCLUSIONS In triplet gestations cervical lengths of < or =2.5 cm between 15 and 24 weeks' gestation and < or =2.0 cm between 25 and 28 weeks' gestation were at least as good as other ultrasonographic cervical parameters for the prediction of spontaneous preterm birth.
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Affiliation(s)
- E R Guzman
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, Saint Peter's University Hospital, New Brunswick 08903, USA
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Meirowitz NB, Guzman ER, Underberg-Davis SJ, Pellegrino JE, Vintzileos AM. Hepatic hemangioendothelioma: prenatal sonographic findings and evolution of the lesion. J Clin Ultrasound 2000; 28:258-263. [PMID: 10800006 DOI: 10.1002/(sici)1097-0096(200006)28:5<258::aid-jcu9>3.0.co;2-k] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
We describe a case of hepatic hemangioendothelioma that was first suspected based on prenatal sonographic findings at 19 weeks' menstrual age. At 16 weeks, the patient presented with a markedly elevated maternal serum alpha-fetoprotein level. Serial sonographic examinations revealed that the fetus had cardiomegaly, hepatomegaly with a hepatic mass and dilated intrahepatic vessels, a single umbilical artery, and a placental chorioangioma. Arteriovenous shunting within the hepatic mass was seen using color Doppler and pulsed Doppler sonography. An enlarged artery arising from the abdominal aorta supplying the mass was demonstrated. Postnatal physical examination and radiologic studies supported the diagnosis of hepatic hemangioendothelioma. The evolution in the sonographic appearance of this hepatic lesion in utero over a 17-week period is described.
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Affiliation(s)
- N B Meirowitz
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, Saint Peter's University Hospital, 254 Easton Avenue, New Brunswick 08903-0591, USA
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Abstract
Sonographic fetal foot length is highly predictive of gestational age. In order to assess the reliability of this parameter in predicting gestational age in cases of abnormal fetal growth, we examined fetal foot length in small- and large-for-gestational-age fetuses. A nomogram of foot length versus gestational age between 15 and 37 weeks was constructed using cross-sectional data obtained from 5372 singleton fetuses. Fetal foot lengths for small-for-gestational-age fetuses (estimated fetal weight below the 10th percentile) and large-for-gestational-age fetuses (above the >90th percentile) fetuses were plotted against the foot length nomogram in order to determine the number of small-for-gestational-age fetuses and large-for-gestational-age fetuses with foot lengths below the 10th and above the 90th percentiles, respectively. Of the 586 small-for-gestational-age fetuses, 355 (60.6%) had foot lengths below the 10th percentile on the nomogram. When foot lengths from large-for-gestational-age fetuses were plotted on the foot length nomogram, 29.4% (219 of 744) had measurements above the 90th percentile. Fetal foot length can be influenced by growth restriction as well as states of accelerated fetal growth. Our findings imply that there are limitations to the use of fetal foot length for gestational age assessment, particularly in fetuses with growth abnormalities.
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Affiliation(s)
- N B Meirowitz
- Department of Obstetrics, Gynecology, and Reproductive Sciences, UMDNJ-Robert Wood Johnson Medical School/St. Peter's University Hospital, New Brunswick, New Jersey 08903-0591, USA
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Vintzileos AM, Guzman ER, Smulian JC, Day-Salvatore DL, Knuppel RA. Indication-specific accuracy of second-trimester genetic ultrasonography for the detection of trisomy 21. Am J Obstet Gynecol 1999; 181:1045-8. [PMID: 10561615 DOI: 10.1016/s0002-9378(99)70078-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The object of this study was to determine whether there are any clinically significant indication-specific variations in the accuracy of second-trimester genetic ultrasonography and to provide a risk adjustment for fetal trisomy 21 according to the results of genetic ultrasonography. STUDY DESIGN From November 1, 1992, to September 30, 1998, a second-trimester genetic sonogram was offered to all pregnant women who were at an increased risk for fetal trisomy 21 (>/=1:274) because of either advanced maternal age (>/=35 years) or abnormal serum biochemical profile or both of these. Outcome information included the results of genetic amniocentesis if performed and the results of pediatric assessment and follow-up after birth. In determining diagnostic accuracy of the genetic sonogram the presence of >/=1 abnormal ultrasonographic marker was considered an abnormal test result. RESULTS A total of 1835 fetuses with known outcomes underwent genetic ultrasonography between 15 and 24 weeks' gestation; of these 1792 had normal results, 34 had trisomy 21, and 9 had other chromosomal abnormalities. The likelihood of fetal trisomy 21 was reduced by 80% after a normal result of genetic ultrasonography. The overall sensitivity, specificity, and positive and negative predictive values of genetic ultrasonography for the detection of trisomy 21 were 82%, 91%, 15%, and 99.6%, respectively. There were no significant indication-specific variations in the accuracy of second-trimester ultrasonography. The sensitivity for the detection of fetal trisomy 21 ranged from 80% among women with advanced maternal age to 100% among women with both an abnormal biochemical profile and advanced maternal age. CONCLUSIONS The likelihood of fetal trisomy 21 risk was reduced 80% after a normal result of genetic ultrasonography. In addition there were no significant indication-specific variations in the detection rate of genetic ultrasonography.
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Affiliation(s)
- A M Vintzileos
- Division of Maternal-Fetal Medicine, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School/St Peter's University Hospital, New Brunswick, USA
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Guzman ER, Shen-Schwarz S, Benito C, Vintzileos AM, Lake M, Lai YL. The relationship between placental histology and cervical ultrasonography in women at risk for pregnancy loss and spontaneous preterm birth. Am J Obstet Gynecol 1999; 181:793-7. [PMID: 10521731 DOI: 10.1016/s0002-9378(99)70303-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Our objective was to determine whether there were any differences in the placental lesions of high-risk patients with versus without ultrasonographic evidence of cervical shortening between 15 and 24 weeks' gestation. STUDY DESIGN Women who were at risk for pregnancy loss and spontaneous preterm birth were followed by serial transvaginal cervical ultrasonography with transfundal pressure between 15 and 24 weeks' gestation. Two groups of women were identified: those in whom progressive cervical shortening developed to below 2 cm, either spontaneously or induced by transfundal pressure, and those in whom it did not. A perinatal pathologist who was blinded to the pregnancy outcome retrospectively examined placental histologic slides. The histologic placental lesions were categorized as acute or chronic inflammatory lesions, decidual vascular lesions, and coagulation-related lesions. RESULTS There were 278 women who were followed during the study. Placentas were submitted for histologic examination in 189 cases (125 singleton, 45 twin, and 19 triplet gestations). There were 72 pregnancies with and 117 pregnancies without an ultrasonographic diagnosis of cervical shortening, respectively. Overall, there were significantly more acute inflammatory lesions in patients in whom cervical shortening developed, as determined by ultrasonographic examination. However, there were significantly more decidual vascular lesions in women in whom cervical shortening did not develop. When we examined the distribution of the placental histologic lesions in the 64 cases of multiple gestations, the only significant finding was again a greater frequency of acute inflammatory lesions in patients in whom cervical shortening developed. There was no difference in the distribution of the placental histologic lesion categories among women treated with bed rest versus cervical cerclage because of the ultrasound diagnosis of cervical shortening. CONCLUSION Acute inflammatory lesions of the placenta were more frequent in patients with second-trimester cervical shortening. These findings support that patients with cervical shortening in the second trimester are prone to acute placental inflammation.
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Affiliation(s)
- E R Guzman
- Division of Maternal-Fetal Medicine, Department of Obstetrics, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, Rochester, Minnesota, USA
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Ranzini AC, Guzman ER, Ananth CV, Day-Salvatore D, Fisher AJ, Vintzileos AM. Sonographic identification of fetuses with Down syndrome in the third trimester: a matched control study. Obstet Gynecol 1999; 93:702-6. [PMID: 10912971 DOI: 10.1016/s0029-7844(98)00492-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To determine sonographic findings in Down syndrome fetuses in the third trimester. METHODS Down syndrome fetuses who had third-trimester ultrasound examinations between 25 and 41 weeks' gestation were matched for gestational age with three controls each. Fetal structural anomalies, Down syndrome dysmorphology markers (abnormal facial profile, sandal gap, tongue thrusting, clinodactyly, or hypoplastic middle phalanx of the fifth finger), and abnormal long-bone biometry (femur, humerus, tibia, and fibula; femur length to biparietal diameter ratio; and femur length to abdominal circumference ratio were abstracted from the ultrasound reports. The fetal face, hands, feet, profile, and cardiac outflow tracts are routinely evaluated in our center. RESULTS Seventeen fetuses with Down syndrome who had third-trimester ultrasound evaluations were identified. Anomalies included cardiac defects (five), tongue thrusting (three), clinodactyly (three), abnormal profile (three), sandal gap (two), and duodenal atresia (two). Of the 17 fetuses, at least one long-bone abnormality was found in 13, at least one structural or biometric anomaly was found in 15, and at least two abnormal findings existed in 11. Abnormal ultrasound findings, including structural anomalies, short bones, and Down syndrome dysmorphology markers, were more common in cases than in matched controls. CONCLUSION At least one abnormal ultrasound finding was present in 15 of 17 fetuses, and abnormal bone measurements or ratios were discovered in 13 of 17. Abnormal long-bone biometry at third-trimester ultrasound should raise the suspicion of fetal Down syndrome.
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Affiliation(s)
- A C Ranzini
- The Center for Perinatal Health Initiatives, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School/St. Peter's Medical Center, New Brunswick, USA
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Abstract
BACKGROUND Reported cases of uterine rupture diagnosed by ultrasound have shown fetal membranes ballooning through uterine rupture sites, or adjacent areas of hemorrhage. CASE A 27-year-old gravida 3, para 2 had open fetal surgery to repair a fetal myelomeningocele at 28 weeks' gestation. Her postoperative course was complicated by threatened preterm labor and anhydramnios. At 33 weeks' gestation, with maternal symptoms of bowel obstruction, ultrasound showed a fetal leg and section of umbilical cord protruding through the uterine wall. CONCLUSION Even in the presence of anhydramnios, uterine wall rupture was identified, because ultrasound evaluation of the uterine wall showed prolapsed fetal parts and umbilical cord. Persistent anhydramnios after open fetal surgery should prompt a search for uterine rupture.
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Affiliation(s)
- A C Ranzini
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School/St. Peter's Medical Center, New Brunswick, USA
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Ranzini AC, Shen-Schwarz S, Guzman ER, Fisher AJ, White M, Vintzileos AM. Prenatal sonographic appearance of hemorrhagic cerebellar infarction. J Ultrasound Med 1998; 17:725-727. [PMID: 9805312 DOI: 10.7863/jum.1998.17.11.725] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
To date, the prenatal diagnosis of cerebellar hemorrhage has been limited to isolated case reports, which have demonstrated either a hyperechoic cerebellar hemisphere or a hyperechoic mass within the cerebellum in near-term fetuses. We demonstrate the ultrasonographic findings of intracerebellar hemorrhagic infarction in a fetus at approximately 21 weeks' gestation. In contrast to previous case reports, the hemorrhagic infarcts seen in our case were hypoechoic.
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Affiliation(s)
- A C Ranzini
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School/St. Peter's Medical Center, New Brunswick 08903-0591, USA
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Guzman ER, Forster JK, Vintzileos AM, Ananth CV, Walters C, Gipson K. Pregnancy outcomes in women treated with elective versus ultrasound-indicated cervical cerclage. Ultrasound Obstet Gynecol 1998; 12:323-327. [PMID: 9819870 DOI: 10.1046/j.1469-0705.1998.12050323.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
OBJECTIVE To compare pregnancy outcomes in women at risk for pregnancy loss treated with elective versus ultrasound-indicated placement of cerclage. METHODS A retrospective cohort study was performed on two groups of patients with singleton gestations. The first group consisted of women at risk for pregnancy loss who were treated with an elective cerclage, while the second group was managed conservatively and followed with serial transvaginal cervical sonography and transfundal pressure. An emergency cerclage was placed in women in the second group when the endocervical canal length shortened to < 20 mm, either spontaneously or in response to transfundal pressure. The two groups were compared with respect to maternal demographics, obstetric and gynecological history, and gestational age, both at time of cerclage placement and delivery. RESULTS A total of 138 patients were identified. Eighty-one patients were treated with an elective cerclage and 57 with an ultrasound-indicated cerclage. Patients treated with elective cerclages were older (32 versus 27 years, p = 0.0003), more commonly white (56.8% versus 38.6%, p = 0.0380), less commonly nulliparous (23.5% versus 43.9%, p = 0.0063), and more often private patients (92.6% versus 28.1%, p < 0.0001). A history of previous treatment with cerclage (45.7% versus 10.5%, odds ratio (OR) 0.2, 95% confidence interval (CI) 0.1-0.4) and one prior midtrimester loss (53.1% versus 33.3%, OR 0.4, 95% CI 0.2-0.9) were also more common in the elective versus ultrasound-indicated cerclage group. However, there was no difference in the rates of previous preterm delivery, two midtrimester losses, two terminations of pregnancy, in utero diethylstilbestrol exposure, uterine anomalies, history of cone biopsy or parity. As expected, gestational age at placement of cerclage was significantly earlier in the elective group (13.0 versus 20.0 weeks, p < 0.0001). The median (range) gestational age at delivery (37 (15-41) versus 37 (17-41) weeks, p = 0.90), the number of early (< 25 weeks) losses (9.9% versus 8.8%, OR 1.6, 95% CI 0.3-7.9), and preterm deliveries (< 37 weeks) (35.8% versus 36.8%, OR 1.1, 95% CI 0.4-3.2) were similar in the elective and ultrasound-indicated cerclage patients, respectively. CONCLUSION In patients at risk for pregnancy loss, placement of cervical cerclages in response to ultrasonographically detected shortening of the endocervical canal length is a medically acceptable alternative to the use of elective cerclage.
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Affiliation(s)
- E R Guzman
- Department of Obstetrics, Gynecology and Reproductive Sciences, St. Peter's Medical Center, New Brunswick, New Jersey 08903-0591, USA
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Guzman ER, Mellon R, Vintzileos AM, Ananth CV, Walters C, Gipson K. Relationship between endocervical canal length between 15-24 weeks gestation and obstetric history. J Matern Fetal Med 1998; 7:269-72. [PMID: 9848691 DOI: 10.1002/(sici)1520-6661(199811/12)7:6<269::aid-mfm3>3.0.co;2-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
The object was to determine whether there is a correlation between the obstetric history and the ultrasonographically determined endocervical canal length between 15 and 24 weeks gestation. A retrospective cohort study was performed in singleton pregnancies of multigravidas with normal and abnormal obstetric histories. They underwent sonographic evaluation for the determination of the endocervical canal length between 15 and 24 weeks gestation. The shortest endocervical canal length measurements between 15 and 20 weeks and also between 21 and 24 weeks of gestation were recorded. An ultrasound diagnosis of cervical incompetence was defined as progressive shortening of the endocervical canal length to <2 cm or a single endocervical canal length measurement <2 cm. A multivariable general linear regression model was used to correlate the relationship between endocervical canal lengths at 15-20 weeks and 21-24 weeks gestation in the current pregnancy with the earliest gestational age at delivery of prior pregnancies. Chi-square test was used to determine the relationship between the development of an ultrasound diagnosis of cervical incompetence and the earliest gestational age at delivery of prior pregnancies. A total of 155 pregnancies were studied. The number of women according to the obstetric history categories were: 57 had delivered <24 weeks, 12 between 24 and 26 weeks, 16 between 27 and 32 weeks, 16 between 33 and 36 weeks, and 54 delivered > or =37 weeks. There was a significant correlation between the endocervical canal length measurements between 15-20 (P < 0.0001) weeks and 21-24 weeks (P < 0.0001) in the studied pregnancy and the earliest gestational age at delivery of prior pregnancies. A significant relationship between the ultrasound diagnosis of cervical incompetence and the obstetric history category (P = 0.0026) was observed. There were 36 cases of ultrasound diagnosed cervical incompetence with 91.7% (33/36) occurring in women who had a prior <27 weeks' gestation delivery. These data provide further evidence that cervical incompetence is a relative condition and not an "all or none" phenomenon. In addition, women with a prior delivery <30 weeks gestation should be followed with second trimester serial cervical sonography to rule out cervical incompetence.
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Affiliation(s)
- E R Guzman
- Department of Obstetrics, Gynecology and Reproductive Sciences, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA.
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Guzman ER, Mellon C, Vintzileos AM, Ananth CV, Walters C, Gipson K. Longitudinal assessment of endocervical canal length between 15 and 24 weeks' gestation in women at risk for pregnancy loss or preterm birth. Obstet Gynecol 1998; 92:31-7. [PMID: 9649088 DOI: 10.1016/s0029-7844(98)00120-3] [Citation(s) in RCA: 93] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To determine the weekly cervical shortening rates of the endocervical canal between 15 and 24 weeks' gestation in women at risk for pregnancy loss or spontaneous preterm birth. METHODS We performed a retrospective cohort study of transvaginal sonographic measurements of the endocervical canal length done at least twice between 15 and 24 weeks' gestation in women at risk for pregnancy loss and spontaneous preterm birth. The ultrasound diagnosis of cervical incompetence was defined as progressive shortening of the endocervical canal length to 2 cm or less either spontaneously or after application of transfundal pressure. Multivariable linear regression models were developed to determine the weekly crude rate of endocervical canal length shortening rates in cases of competent cervices and incompetent cervices, with incompetent cervices further stratified as those diagnosed at 15-19 weeks' and 20-24 weeks' gestation. Comparisons of the models for weekly rate of endocervical canal length shortening were performed. RESULTS The endocervical canal lengths were measured in 61 women (180 measurements) who did not develop ultrasound evidence of cervical incompetence and 28 women (103 measurements) who had ultrasound evidence of cervical incompetence. Between 15 and 24 weeks' gestation, competent cervices had a nonsignificant rate of endocervical canal length shortening (-0.03 cm/week). During this period in gestation, incompetent cervices had significantly greater endocervical canal length shortening (-0.41 cm/week, P < .001). The rate of endocervical canal length shortening of incompetent cervices diagnosed between 15 and 19 weeks' gestation was -0.52 cm/week (P < .001). The rate of endocervical canal length shortening in incompetent cervices diagnosed between 20 and 24 weeks' gestation was significant and varied from -0.49 cm/week to -0.80 cm/week at 20 and 24 weeks' gestation, respectively (P < .001). The models describing the rate of cervical shortening in the two groups of incompetent cervices were significantly different (P < .001). The sonographic detection of endocervical canal length shortening in the 28 cases of cervical incompetence was identified at a median (range) gestational age of 20 (16-24) weeks. CONCLUSION Weekly rates of endocervical canal length shortening were established, which may be useful for detecting and managing cervical incompetence in high-risk women examined with cervical sonography.
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Affiliation(s)
- E R Guzman
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, St. Peter's Medical Center, New Brunswick 08903-0591, USA.
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Guzman ER, Vintzileos A, Egan JF, Benito C, Lake M, Lai YL. Antenatal prediction of fetal pH in growth restricted fetuses using computer analysis of the fetal heart rate. J Matern Fetal Med 1998; 7:43-7. [PMID: 9502670 DOI: 10.1002/(sici)1520-6661(199801/02)7:1<43::aid-mfm10>3.0.co;2-m] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
We tested the accuracy of a mathematical model based on computer analysis of the fetal heart rate tracing in predicting umbilical artery pH at birth. In a previous report based on data on 38 growth-restricted fetuses, the second-order polynomial regression equation, umbilical artery pH = 7.28 + 0.002 (duration of episodes of low variation in minutes) + 0.00009 (duration of episodes of low variation in minutes), was retrospectively found to be the best model for the prediction of umbilical artery pH at birth. In the present study, this formula was prospectively tested in 29 growth restricted fetuses between 26 and 37 weeks of gestation from pregnancies with abnormal uterine and/or umbilical artery Doppler velocimetry. Computer analysis of the fetal heart rate tracing of 1 hour duration was performed within 1.5-6 hours of cesarean birth prior to the onset of labor. Umbilical artery cord blood was collected at birth with pH determined within 5 minutes of collection. Acidemia was defined as umbilical artery pH < 7.20, preacidemia pH 7.20-7.25 and nonacidemia pH > 7.25. Then, the data on all 67 growth-restricted fetuses were pooled to generate a new formula that was retrospectively assessed against the entire group. Values are reported as median (range). In the 29 prospectively evaluated cases, there was no statistical difference between the predicted and actual umbilical artery pH at birth [7.28 (7.1-7.29) vs. 7.28 (7.18-7.37), P = 0.57]. The median difference between the paired predicted and actual umbilical artery pH values was -0.001 (-0.10-0.08). The difference between the predicted and actual umbilical artery pH was zero and within +/- 0.04 in 17% (5/29) and 76% (22/29) of the cases, respectively. When the data on the 67 growth-restricted fetuses were pooled together the formula did not change. There was no difference between the predicted and actual umbilical artery pH at birth when the formula was applied to all 67 growth-restricted fetuses [7.28 (7.08-7.29) vs. 7.27 (6.97-7.37), P = 0.41]. The median difference between the paired predicted and actual pH values was -0.001 (-0.12-0.12). The difference between the predicted and actual umbilical artery pH was zero and within +/- 0.04 in 15% (10/67) and 74% (49/67) of the cases, respectively. The accuracy of the formula in correctly categorizing the umbilical artery pH at birth was: acidemia 67% (8/12), preacidemia 28% (8/29) and nonacidemia 80% (37/46), P < 0.0001. A mathematical formula using the computer analysis index of duration of episodes of low variation reliably predicted umbilical artery pH at birth. This type of noninvasive monitoring may allow for the antepartum estimation and continuous tracking of fetal pH.
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Affiliation(s)
- E R Guzman
- Department of Obstetrics and Gynecology and Reproductive Sciences, UMDNJ-Robert Wood Johnson Medical School, St. Peter's Medical Center, New Brunswick, New Jersey 08903, USA
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Guzman ER, Pisatowski DM, Vintzileos AM, Benito CW, Hanley ML, Ananth CV. A comparison of ultrasonographically detected cervical changes in response to transfundal pressure, coughing, and standing in predicting cervical incompetence. Am J Obstet Gynecol 1997; 177:660-5. [PMID: 9322639 DOI: 10.1016/s0002-9378(97)70161-3] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Our purpose was to compare various noninvasive stress techniques for their ability to elicit ultrasonographic cervical changes and to determine their efficacy in detecting ultrasonographic cervical incompetence. STUDY DESIGN Eighty-nine patients at risk for pregnancy loss and preterm birth underwent ultrasonographic evaluation of the cervix at least twice between 15 and 24 weeks of gestation. With use of a transvaginal probe, the funnel width, funnel length, and endocervical canal length were measured in millimeters with the patient in the supine position. These measurements were repeated after three stress tests: transfundal pressure, coughing, and standing. The difference between the baseline measurements and those obtained after the stress tests were determined. A positive response to stress was defined as any decrease in endocervical canal length accompanied by an increase in funnel width and length. Improvement was defined by any increase in endocervical canal length accompanied by a decrease in funnel width and length. Cervical incompetence was defined as the presence of progressive cervical changes on ultrasonographic examinations with final endocervical canal length measurements below 26 mm. Results are reported as median (range). RESULTS The number of positive cervical responses to transfundal pressure (19%, 17/89) was significantly greater than to coughing (3.3%, 3/89) and standing (9.0%, 8/89). The status of the cervix improved with standing in three cases, whereas this was not seen with transfundal pressure or coughing. There was no case where there was a positive response to standing or coughing and not to transfundal pressure. When the changes in funnel width and length and endocervical canal length as a result of transfundal pressure and standing in the 17 cases that responded to transfundal pressure, transfundal pressure resulted in a significantly greater increase in funnel width and length and a decrease in endocervical canal length. The efficacy of transfundal pressure in detecting the cervix that had subsequent progressive changes on ultrasonography was as follows: sensitivity 83.3%, specificity 97.2%, and positive and negative predictive values 88.2% and 95.8%, respectively. The efficacy of coughing was sensitivity 16.7%, specificity 100%, and positive and negative predictive values 100% and 85.5%, respectively. The efficacy of standing was sensitivity 33.3%, specificity 97.2%, and positive and negative predictive values 75% and 85.2%, respectively. Similar results were obtained when the analysis was confined to 37 patients who had a prior history of a midtrimester miscarriage. CONCLUSION Transfundal pressure was the most effective technique in eliciting cervical changes during the active assessment of the cervix during pregnancy and the most sensitive in detecting the cervix that had progressive second-trimester cervical shortening during pregnancy, compared with coughing or standing position.
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Affiliation(s)
- E R Guzman
- Department of Obstetrics and Gynecology and Reproductive Sciences, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, New Brunswick, USA
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Abstract
OBJECTIVE To determine the utilization rate of second-trimester genetic sonogram and its role in influencing the decision for amniocentesis in women at increased risk for fetal trisomy 21. METHODS From November 1, 1993, to December 31, 1996, a second-trimester genetic sonogram or only genetic amniocentesis (as a first choice) were offered to pregnant women referred to our institution who were at increased risk for fetal trisomy 21. RESULTS During the study period, 2089 women were referred to our unit for genetic prenatal diagnosis; of these, 1426 (68%) chose only genetic amniocentesis, and 663 (32%) chose a genetic sonogram as their first option. The yearly utilization rates of genetic sonogram were two of 477 or 0.4% for 1993, 82 of 495 or 16.6% for 1994, 251 of 523 or 48.0% for 1995, and 328 of 594 or 55.2% for 1996. Adjusting for potential confounders, multivariable logistic regression analysis showed that the most important factors associated with the women's decision to undergo genetic amniocentesis were three or more ultrasound markers present (relative risk [RR] 189.5, 95% confidence interval [CI] 37.1, 980.0), two ultrasound markers present (RR 47.2, 95% CI 9.8, 267.8), one ultrasound marker present (RR 12.7, 95% CI 5.5, 29.7), and abnormal serum biochemistry (RR 3.0, 95% CI 1.0, 8.9). CONCLUSION The increasing utilization trend, in conjunction with the fact that an abnormal sonogram was the most influential factor in women's decision to undergo genetic amniocentesis, suggests that genetic sonogram services for detection of trisomy 21 should be added to the armamentarium of all prenatal diagnostic centers.
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Affiliation(s)
- A M Vintzileos
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School/St. Peter's Medical Center, New Brunswick, USA.
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Hoffman CT, Guzman ER, Richardson MJ, Vintzileos A, Houlihan C, Benito C. Effects of narcotic and non-narcotic continuous epidural anesthesia on intrapartum fetal heart rate tracings as measured by computer analysis. J Matern Fetal Med 1997; 6:200-5. [PMID: 9260115 DOI: 10.1002/(sici)1520-6661(199707/08)6:4<200::aid-mfm2>3.0.co;2-n] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To evaluate the effect of narcotic and non-narcotic continuous epidural anesthesia on intrapartum fetal heart rate (FHR) tracings as measured by computer analysis. METHODS We studied 37 women with uncomplicated pregnancies at term with reactive FHR tracings. The women were randomized to receive epidural anesthesia with either bupivicaine with fentanyl or bupivicaine alone. One-hour FHR tracings were obtained before epidural anesthesia. Thirty minutes after the initial bolus of the epidural a repeat computer analysis of 60-minute FHR tracing was obtained. Median values are reported for FHR parameters with statistical analysis performed by the Mann-Whitney U and Wilcoxon signed rank tests where appropriate. A power calculation was performed using a power of 90% to determine a required sample size of 28 patients. Statistical significance was set at P < .05. RESULTS In early first stage of labor, there was no significant difference in pre- and postepidural anesthesia FHR baseline, accelerations of 10 and 15 beats per minute, episodes of high and low variation, and short- and long-term variation when using either narcotic or non-narcotic anesthetic agents. CONCLUSIONS Thus, the clinician can consider the use of narcotic as well as non-narcotic continuous epidural anesthesia in the dosages used in our study with its attendant advantages without fear of obscuring the fetal heart rate tracing.
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Affiliation(s)
- C T Hoffman
- Department of Obstetrics and Gynecology and Reproductive Sciences, UMDNJ-Robert Wood Johnson Medical School, St. Peter's Medical Center, New Brunswick 08901, USA
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Vintzileos AM, Campbell WA, Guzman ER, Smulian JC, McLean DA, Ananth CV. Second-trimester ultrasound markers for detection of trisomy 21: which markers are best? Obstet Gynecol 1997; 89:941-4. [PMID: 9170470 DOI: 10.1016/s0029-7844(97)00152-x] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To investigate which second-trimester ultrasound markers for aneuploidy are the most diagnostically efficient in detecting fetal trisomy 21. METHODS All second-trimester genetic sonograms performed since November 1, 1992 for women at increased risk for fetal trisomy 21 were analyzed retrospectively. Statistical analysis included descriptive statistics, the test of proportions, and univariate and multivariable logistic regression analysis using trisomy 21 as the dependent variable and ten aneuploidy ultrasound markers as independent variables. RESULTS There were 581 normal fetuses, 23 with trisomy 21 and four with other chromosomal abnormalities. When one or more abnormal ultrasound markers were present, the sensitivity and false-positive rate for trisomy 21 were 87% and 13.4%, respectively. After adjusting for confounders, multivariate logistic regression analysis showed the best combination of ultrasound markers for detecting trisomy 21 to be nuchal fold thickening (relative risk [RR] 85.5; 95% confidence interval [CI] 20.4, 357.7), pyelectasis (RR 25.2; 95% CI 6.7, 95.0), and short humerus (RR 20.4; 95% CI 4.5, 92.1). The model combining these three ultrasound markers yielded a sensitivity of 87% and a false-positive rate of 6.7%. CONCLUSION By using only three ultrasound markers (combination of nuchal fold thickening, pyelectasis, and short humerus) the false-positive rate is decreased from 13.4% to 6.7% without any compromise in the sensitivity (87%). The clinical usefulness of evaluating the various second-trimester ultrasound markers needs to be evaluated in prospective studies.
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Affiliation(s)
- A M Vintzileos
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School/St. Peter's Medical Center, New Brunswick, USA
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Guzman ER, Vintzileos AM, McLean DA, Martins ME, Benito CW, Hanley ML. The natural history of a positive response to transfundal pressure in women at risk for cervical incompetence. Am J Obstet Gynecol 1997; 176:634-8. [PMID: 9077619 DOI: 10.1016/s0002-9378(97)70560-x] [Citation(s) in RCA: 51] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Our purpose was to observe the evolution of the endocervical canal length in women at risk for cervical incompetence after a positive response to transfundal pressure. STUDY DESIGN Ten women at risk for cervical incompetence had a midtrimester cervical evaluation with transvaginal ultrasonography and transfundal pressure. With a transvaginal probe, the endocervical canal length was first measured. Transfundal pressure was then applied and the endocervical canal length was remeasured. All patients had a positive response to transfundal pressure as defined by a decrease in endocervical canal length after application of transfundal pressure. At the initial evaluation the digital examination of the cervix had revealed a closed and long cervix in all 10 cases. In 9 of the 10 patients repeat examinations were performed until the endocervical canal length progressively shortened to <10 mm or the digital examination revealed a dilated cervix. The endocervical canal lengths after application of transfundal pressure from the first and last examination were compared. One patient was lost to follow-up, but the obstetric outcome was available. RESULTS The median time interval between the first and final examination was 7 (2 to 20) days in 9 of the patients. The median (range) gestational age at the first and final examination was 19.0 (15 to 22) weeks (n = 10) and 20.5 (18 to 24) weeks (n = 9), respectively. There was significant shortening of the endocervical canal length from the first to the last examination; 12.2 (4 to 20) mm (n = 10) versus 0.0 (0 to 9.5) mm (n = 9), p = 0.008. Six patients had membranes at the external cervical os before application of transfundal pressure at the last examination. The one patient lost to ultrasonographic follow-up had a pregnancy loss at 23 weeks of gestation, 6 weeks after a positive response to transfundal pressure. CONCLUSION In patients at risk for cervical incompetence, shortening of the endocervical canal length in response to transfundal pressure requires treatment with a cervical cerclage because it is associated with progressive cervical changes over 1 to 3 weeks.
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Affiliation(s)
- E R Guzman
- Department of Obstetrics and Gynecology and Reproductive Sciences, University of Medicine and Dentistry-Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
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Vintzileos AM, Guzman ER, Smulian JC, McLean DA, Ananth CV. Utilization of second-trimester genetic sonogram for detection of trisomy 21 and its role in influencing women's decision to undergo amniocentesis. Am J Obstet Gynecol 1997. [DOI: 10.1016/s0002-9378(97)80277-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Smulian JC, Guzman ER, Ranzini AC, Benito CW, Vintzileos AM. Color and duplex Doppler sonographic investigation of in utero spontaneous regression of pulmonary sequestration. J Ultrasound Med 1996; 15:789-792. [PMID: 8908591 DOI: 10.7863/jum.1996.15.11.789] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
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.
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Affiliation(s)
- J C Smulian
- Department of Obstetrics, Gynecology, and Reproductive Sciences, UMDNJ-Robert Wood Johnson Medical School, St. Peter's Medical Center, New Brunswick 08903-0591, USA
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Guzman ER, Vintzileos A, Benito C, Houlihan C, Waldron R, Egan S. Effects of therapeutic amniocentesis on uterine and umbilical artery velocimetry in cases of severe symptomatic polyhydramnios. J Matern Fetal Med 1996; 5:299-304. [PMID: 8972403 DOI: 10.1002/(sici)1520-6661(199611/12)5:6<299::aid-mfm1>3.0.co;2-k] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- E R Guzman
- Department of Obstetrics, Gynecology and Reproductive Sciences, UMDNJ-Robert Wood Johnson Medical School, St. Peter's Medical Center, New Brunswick 08903-0591, USA
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Guzman ER, Houlihan C, Vintzileos A, Ivan J, Benito C, Kappy K. The significance of transvaginal ultrasonographic evaluation of the cervix in women treated with emergency cerclage. Am J Obstet Gynecol 1996; 175:471-6. [PMID: 8765271 DOI: 10.1016/s0002-9378(96)70164-3] [Citation(s) in RCA: 65] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- E R Guzman
- Department of Obstetrics and Gynecology and Reproductive Sciences, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, St. Peter's Medical Center, New Brunswick 08903-0591, USA
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Vintzileos AM, Egan JF, Smulian JC, Campbell WA, Guzman ER, Rodis JF. Adjusting the risk for trisomy 21 by a simple ultrasound method using fetal long-bone biometry. Obstet Gynecol 1996; 87:953-8. [PMID: 8649705 DOI: 10.1016/0029-7844(96)00058-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- A M Vintzileos
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Robert Wood Johnson Medical School/St. Peter's Medical Center, University of Medicine and Dentistry of New Jersey, New Brunswick, USA
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Vintzileos AM, Campbell WA, Rodis JF, Guzman ER, Smulian JC, Knuppel RA. The use of second-trimester genetic sonogram in guiding clinical management of patients at increased risk for fetal trisomy 21. Obstet Gynecol 1996; 87:948-52. [PMID: 8649704 DOI: 10.1016/0029-7844(96)00053-1] [Citation(s) in RCA: 77] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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%.
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Affiliation(s)
- A M Vintzileos
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School/St. Peter's Medical Center, New Brunswick, USA
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Guzman ER, Vintzileos AM, Martins M, Benito C, Houlihan C, Hanley M. The efficacy of individual computer heart rate indices in detecting acidemia at birth in growth-restricted fetuses. Obstet Gynecol 1996; 87:969-74. [PMID: 8649708 DOI: 10.1016/0029-7844(96)00020-8] [Citation(s) in RCA: 77] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- E R Guzman
- Department of Obstetrics, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, New Brunswick, USA
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Guzman ER, Benito C, Hanley M. Sonography in the evaluation of the cervix during pregnancy. Curr Opin Obstet Gynecol 1996; 8:99-105. [PMID: 8734123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Sonographic techniques have been developed to study the biometry and behavior of the cervix during pregnancy which have led to a better understanding of the pathogenesis of pregnancy loss and preterm birth. Nomograms have been developed for singleton and twin gestations, and associations between cervical sonographic characteristics and various adverse pregnancy outcomes have been observed. The new concept of 'relative' cervical incompetence suggests that the cervix may be an independent contributor to preterm birth. The incorporation of cervical sonography in management schemes for the prevention of pregnancy loss or preterm delivery has the potential to impact favorably on perinatal outcome.
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Affiliation(s)
- E R Guzman
- Department of Obstetrics and Gynecology and Reproductive Sciences, University of Medicine and Dentistry, Robert Wood Johnson Medical School, St Peter's Medical Center, New Brunswick, NJ 08003, USA
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Abstract
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.
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Affiliation(s)
- J C Smulian
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Robert Wood Johnson Medical School-St Peter's Medical Center, University of Medicine and Dentistry of New Jersey, New Brunswick 08903-0591, USA
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Benito CW, Guzman ER, Vintzileos AM. The use of ultrasonography in the labor and delivery suite. Clin Perinatol 1996; 23:117-39. [PMID: 8689800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- C W Benito
- Department of Obstetrics and Gynecology and Reproductive Sciences, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School/St. Peter's Medical Center, New Brunswick, USA
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Abstract
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.
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Affiliation(s)
- A M Vintzileos
- Department of Obstetrics, Gynecology and Reproductive Sciences, Robert Wood Johnson Medical School/St. Peter's Medical Center, University of Medicine and Dentistry of New Jersey 08903, USA
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Hanley ML, Guzman ER, Vintzileos AM, Leiman S, Doyle A, Shen-Schwarz S. Prenatal ultrasonographic detection of regression of an encephalocele. J Ultrasound Med 1996; 15:71-74. [PMID: 8667488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Affiliation(s)
- M L Hanley
- Department of Maternal-Fetal Medicine, UMDNJ Robert Wood Johnson Medical School, New Brunswick, NJ 08903-0591, USA
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Vintzileos AM, Nochimson DJ, Antsaklis A, Varvarigos I, Guzman ER, Knuppel RA. Comparison of intrapartum electronic fetal heart rate monitoring versus intermittent auscultation in detecting fetal acidemia at birth. Am J Obstet Gynecol 1995; 173:1021-4. [PMID: 7485287 DOI: 10.1016/0002-9378(95)91320-3] [Citation(s) in RCA: 50] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVE Our purpose was to compare continuous intrapartum electronic fetal heart rate monitoring with intermittent auscultation for detecting fetal acidemia at birth. STUDY DESIGN Data from a previously published randomized trial of electronic fetal heart rate monitoring versus intermittent auscultation were analyzed to identify any differences between the two methods in detecting fetal acidemia at birth. Fetal acidemia at birth was defined as the presence of cord blood arterial pH < 7.15. RESULTS A total of 1419 patients with umbilical cord blood acid-base measurements were identified, 739 in the electronic FHR monitoring group and 680 in the auscultation group. Electronic FHR monitoring had significantly better sensitivity (97% vs 34%, p < 0.001), lower specificity (84% vs 91%, p < 0.001), higher positive predictive value (37% vs 22%, p < 0.05), and higher negative predictive value (99.5% vs 95%, p < 0.001) in detecting fetal acidemia at birth. In addition, electronic FHR monitoring was significantly better in detecting all types of acidemia: metabolic (95.5% vs 26.5%, p < 0.001), mixed (95% vs 37.5%, p < 0.001), and respiratory (100% vs 41.5%, p < 0.001). CONCLUSION These data suggest that electronic FHR monitoring is superior to intermittent auscultation in detecting fetal acidemia at birth.
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Affiliation(s)
- A M Vintzileos
- Department of Obstetrics, Gynecology, and Reproductive Sciences, RobertWood Johnson Medical School/St. Peter's Medical Center, University of Medicine and Dentistry of New Jersey, New Brunswick, USA
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Giannina G, Guzman ER, Lai YL, Lake MF, Cernadas M, Vintzileos AM. Comparison of the effects of meperidine and nalbuphine on intrapartum fetal heart rate tracings. Obstet Gynecol 1995; 86:441-5. [PMID: 7651658 DOI: 10.1016/0029-7844(95)00164-m] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVE To examine the effects of meperidine and nalbuphine on intrapartum fetal heart rate (FHR) tracings using computer analysis. METHODS We studied 28 women with uncomplicated pregnancies in early labor at term with reactive FHR tracings. The women were randomized to receive either meperidine 50 mg or nalbuphine 10 mg intravenously on request. One-hour FHR recordings were obtained before and immediately after administration of the medications. RESULTS There were no significant differences in the FHR characteristics of the two groups during the pre-treatment period. Nalbuphine significantly decreased the number of accelerations of 10 beats per minute (17 versus 4, P = .003) and 15 beats per minute (10 versus 1.5, P = .001), time spent in episodes of high variation (35.5 versus 10 minutes, P = .004), long-term variation (47 versus 29.8 milliseconds, P = .002), and short-term variation (8.4 versus 6.4 milliseconds, P = .03). Meperidine had no significant effect on any FHR characteristic. CONCLUSION In the early intrapartum period of normal term pregnancies and at commonly used dosages, nalbuphine had a significant effect on FHR tracings, whereas meperidine had no effect, as determined by computer analysis.
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Affiliation(s)
- G Giannina
- Department of Obstetrics, Gynecology, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, St. Peter's Medical Center, New Brunswick, USA
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Sharma S, Gray S, Guzman ER, Rosenberg JC, Shen-Schwarz S. Detection of twin-twin transfusion syndrome by first trimester ultrasonography. J Ultrasound Med 1995; 14:635-637. [PMID: 7474066 DOI: 10.7863/jum.1995.14.8.635] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Affiliation(s)
- S Sharma
- Department of Maternal-Fetal Medicine, UMDNJ-Robert Wood Johnson Medical School, St. Peter's Medical Center, New Brunswick, New Jersey 08901, USA
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Guzman ER, Ranzini A, Day-Salvatore D, Weinberger B, Spigland N, Vintzileos A. The prenatal ultrasonographic visualization of imperforate anus in monoamniotic twins. J Ultrasound Med 1995; 14:547-551. [PMID: 7563305 DOI: 10.7863/jum.1995.14.7.547] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Affiliation(s)
- E R Guzman
- Division of Maternal-Fetal Medicine, UMDNJ-Robert Wood Johnson Medical School, St. Peter's Medical Center, New Brunswick, New Jersey 08903-0591, USA
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Abstract
Ultrasonographic evaluation of the cervix in pregnancy has provided some insight into premature delivery and pregnancy wastage. Its use has led to the development of cervical length nomograms in uncomplicated singleton pregnancies and to the realization that varying degrees of cervical incompetence exist. In some instances the internal os has been observed to dilate and funnel in the early second trimester while in others these changes occur gradually into the third trimester. Transient cervical changes have been linked to premature delivery and extended ultrasonographic inspection is required for their detection. Although sonography may allow the identification of women who deliver prematurely, it has not demonstrated enough discriminatory power to recommend its routine use for this purpose. Pre- and postoperative inspection of the cervix in elective and emergency cerclage procedures may become influential in outpatient management. A method of functional evaluation of the cervix using transfundal pressure (TFP) has been introduced which may lead to earlier diagnosis of cervical incompetence. The significance of descent of the membranes in response to TFP and sonographic findings consistent with premature cervical changes have not been validated because of surgical intervention performed in response to these findings. Our review concludes that, although sonography of the cervix may be useful in selective cases, more information on the natural history of abnormal cervical sonographic findings and controlled randomized trials are needed before recommendations on surgical intervention can be made.
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Affiliation(s)
- E R Guzman
- Department of Obstetrics and Gynecology and Reproductive Sciences, University of Medicine and Dentistry-Robert Wood Johnson Medical School, St. Peter's Medical Center, New Brunswick, NJ 08903-0591, USA
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Vintzileos AM, Nochimson DJ, Guzman ER, Knuppel RA, Lake M, Schifrin BS. Intrapartum electronic fetal heart rate monitoring versus intermittent auscultation: a meta-analysis. Obstet Gynecol 1995; 85:149-55. [PMID: 7800313 DOI: 10.1016/0029-7844(94)00320-d] [Citation(s) in RCA: 184] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To use a meta-analysis of all published randomized trials to determine whether the use of continuous electronic fetal heart rate monitoring (EFM) as the main method of intrapartum fetal surveillance is associated with improved pregnancy outcome compared to intermittent auscultation. DATA SOURCES We used the MEDLINE data base and reference lists of articles to identify all published randomized trials of EFM versus intermittent auscultation. METHODS OF STUDY SELECTION A total of nine randomized trials published in peer-review journals were identified. The selection criterion was the use of EFM or intermittent auscultation as the main intrapartum fetal surveillance technique. DATA EXTRACTION AND SYNTHESIS A total of 18,561 patients were included in the nine published randomized trials, 9398 in the EFM group and 9163 in the auscultation group. Measures of pregnancy outcome included cesarean delivery, cesarean for suspected fetal distress, overall use of forceps or vacuum, use of forceps or vacuum for suspected fetal distress, overall perinatal mortality, and perinatal mortality due to fetal hypoxia (intrapartum or early neonatal death) attributable to the method of intrapartum monitoring. The meta-analysis showed that the patients monitored electronically had a significantly higher overall cesarean rate (odds ratio [OR] 1.53, 95% confidence interval [CI] 1.17-2.01), higher cesarean rate for fetal distress (OR 2.55, 95% CI 1.81-3.53), overall increased use of forceps or vacuum (OR 1.23, 95% CI 1.02-1.49), increased use of forceps or vacuum for suspected fetal distress (OR 2.50, 95% CI 1.97-3.18), and decreased perinatal mortality due to fetal hypoxia (OR 0.41, 95% CI 0.17-0.98). CONCLUSION Electronic fetal monitoring is associated with increased rates of surgical intervention and decreased perinatal mortality due to fetal hypoxia.
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Affiliation(s)
- A M Vintzileos
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Robert Wood Johnson Medical School/St. Peter's Medical Center, University of Medicine and Dentistry of New Jersey, New Brunswick
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45
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Abstract
Transabdominal ultrasonography in obese pregnant women is often unsatisfactory because of the poor transmission of ultrasound through a thickened abdominal wall. We report our experience with the placement of a transvaginal probe in the umbilicus to improve resolution in obese pregnant patients. The technique, which involves filling the umbilicus with ultrasound transmission gel and inserting the transvaginal probe into the umbilicus, was applied in 25 consecutive obese patients who had unsatisfactory fetal imaging by the standard transabdominal approach. The most frequent reason for incomplete fetal survey by the standard transabdominal approach was unsatisfactory imaging of the fetal heart (19 of 25 cases, 76%). The transumbilical approach resulted in improved resolution and satisfactory cardiac examination in 18 of these 19 cases (95%). In two cases, color and pulsed Doppler interrogation of intrafetal vessels become possible. A complete fetal survey was accomplished in 96% of the cases.
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Affiliation(s)
- J C Rosenberg
- Department of Obstetrics and Gynecology, Robert Wood Johnson Medical School/St. Peter's Medical Center, University of Medicine and Dentistry, New Brunswick, New Jersey
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Westover T, Guzman ER, Shen-Schwarz S. Prenatal diagnosis of an unusual nuchal cord complication in monoamniotic twins. Obstet Gynecol 1994; 84:689-91. [PMID: 9205450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Monoamniotic twin pregnancies are frequently associated with cord entanglement, but such entanglement rarely involves the co-twin's trunk, extremities, or neck. CASE We report a set of monoamniotic twins in which color Doppler imaging revealed that the cord of twin B was wrapped around the neck of its dead co-twin. This knowledge allowed us to avoid clamping and dividing twin A's nuchal cord during vaginal delivery, preventing asphyxia of twin B. This is the fifth reported incidence of this particular monoamniotic complication and the first to be diagnosed prenatally. CONCLUSION Color Doppler imaging facilitates the diagnosis of rare cord complications in monoamniotic twin pregnancies.
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Affiliation(s)
- T Westover
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Robert Wood Johnson Medical School, St. Peter's Medical Center, University of Medicine and Dentistry of New Brunswick, USA
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Guzman ER, Rosenberg JC, Houlihan C, Ivan J, Waldron R, Knuppel R. A new method using vaginal ultrasound and transfundal pressure to evaluate the asymptomatic incompetent cervix. Obstet Gynecol 1994; 83:248-52. [PMID: 8290189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVE To evaluate the ability of ultrasound with transfundal pressure to detect the incompetent cervix in pregnant women at risk for this condition. METHODS One hundred fifty pregnant women with no prior pregnancy losses were scanned transabdominally, and 31 asymptomatic pregnant women with a prior history of cervical incompetency or risk for this condition were scanned transvaginally. The control patients were scanned once between 16-24 weeks, and the patients at risk were studied 73 times between 8-25 weeks. After evaluating the cervix and its internal os, transfundal pressure was applied. Cervical cerclages were placed for cervical funneling and shortening in response to transfundal pressure or for a grossly incompetent cervix on ultrasound evaluation. RESULTS Transfundal pressure elicited no changes in the internal cervical os of the 150 control patients, of whom 141 delivered at term, two miscarried at 22 and 23 weeks, and seven delivered prematurely (4.7%). Fourteen of the 31 pregnancies at risk for cervical incompetency revealed opening of the internal os or descent of the fetal membranes with transfundal pressure. Thirteen of these 14 pregnancies were treated with cerclage, with nine (64%) proceeding to term, three (21%) delivering prematurely, and two (14%) aborting. The one patient who did not receive a cerclage also aborted. In six cases, the cervix and its internal os appeared normal but the membranes protruded into the endocervical canal in response to transfundal pressure. CONCLUSION Application of transfundal pressure during transvaginal ultrasound evaluation of the cervix and its internal os may assist in detecting the asymptomatic incompetent cervix.
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Affiliation(s)
- E R Guzman
- Department of Obstetrics and Gynecology, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, New Brunswick
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Guzman ER, Day-Salvatore D, Westover T, Rosenberg JC, Beim D, Grabelle H. Prenatal ultrasonographic demonstration of the trident hand in heterozygous achondroplasia. J Ultrasound Med 1994; 13:63-66. [PMID: 7636958 DOI: 10.7863/jum.1994.13.1.63] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Affiliation(s)
- E R Guzman
- Division of Maternal-Fetal Medicine, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, New Jersey 08903-0591, USA
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Guzman ER, Conley M, Stewart R, Ivan J, Pitter M, Kappy K. Phenytoin and magnesium sulfate effects on fetal heart rate tracings assessed by computer analysis. Obstet Gynecol 1993; 82:375-9. [PMID: 8355937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVE To compare the effects of maternally administered phenytoin and magnesium sulfate on the fetal heart rate (FHR) using computer analysis. METHODS Thirty-six nonlaboring preeclamptic women between 27-41 weeks' gestation were treated with either phenytoin or magnesium sulfate in a nonrandomized fashion. All fetuses were deemed to be well by traditional electronic-biophysical criteria. One-hour FHR recordings were analyzed by computer analysis before treatment. No other medications were administered. Tracings recorded 1 hour after drug administration were analyzed. Therapeutic serum levels were achieved in both groups before FHR tracings were reevaluated. Statistical analysis used paired Student t test, with significance set at P < or = .05. RESULTS There were no differences in birth weight, gestational age, Apgar scores, or computer-analyzed FHR characteristics between the groups before treatment. Magnesium sulfate reduced significantly the frequency of accelerations of ten and 15 beats per minute; caused a 62% reduction in reactivity, defined as accelerations of 15 beats per minute in 20 minutes of FHR tracing (but no change in reactivity with accelerations of ten beats per minute); and reduced short- and long-term variability. Phenytoin reduced short-term variability only. CONCLUSION Phenytoin does not confound the computer analysis of FHR tracings and may offer some advantage over magnesium sulfate when used for prophylaxis against eclampsia.
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Affiliation(s)
- E R Guzman
- Department of Obstetrics and Gynecology, Newark Beth Israel Medical Center, New Jersey
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50
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Abstract
A case is reported in which gastroschisis was definitively diagnosed at 12 3/7 weeks' gestation by transvaginal ultrasonography. This is the earliest diagnosis reported in the literature and would seem to support the theory that gastroschisis and omphalocele are embryologically distinct entities.
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Affiliation(s)
- E R Guzman
- Department of Obstetrics and Gynecology, St. Vincent's Medical Center of Richmond, Staten Island, New York
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