Does amniotic fluid alpha-fetoprotein have diagnostic or prognostic value at the time of second midtrimester genetic amniocentesis?

In order to assess the usefulness of amniotic fluid alpha-fetoprotein (AFP) levels at the time of midtrimester genetic amniocentesis, 4,430 cases were retrospectively studied to compare the high, normal or low AFP values with the karyotype characteristics and fetal anatomy using ultrasound (US) scanning and confirmed by postnatal evaluation or necroscopy in the case of termination of pregnancy. All the cases presenting malformations were correctly diagnosed by US examinations. AFP levels over the 2nd standard deviation (SD) were found in 112 cases (2.52%) and below the 2nd SD in 11 cases (0.24%). The characteristics of these cases are presented and discussed. According to our results, it is concluded that routine assessment of AFP at the time of midtrimester genetic amniocentesis, if coupled with optimal US scanning, is no longer justified.

Can the degree of retrograde diastolic flow in abnormal umbilical artery flow velocity waveforms predict pregnancy outcome?

OBJECTIVE

Reverse end-diastolic flow is the most pathological type of the umbilical artery flow velocity waveform. We aimed to investigate whether additional prognostic information can be obtained from umbilical artery waveforms in cases with reverse end-diastolic flow.

SUBJECTS AND METHODS

Umbilical artery Doppler velocity waveforms from 44 fetuses with reverse end-diastolic flow were analyzed and the following parameters measured: the highest amplitude and the area below the maximum velocity curve of forward and reverse flow (A, B and C, D, respectively) and the duration of forward and reverse flow (Tc and Td, respectively). Ratios A/B, C/D and Tc/Td were calculated. The cut-off values for A/B, C/D and Tc/Td with the best predictive values for perinatal death were established with the help of receiver operating characteristics curves. The three curves were compared with each other.

RESULTS

Of the three ratios, A/B and C/D had the best capacity to predict perinatal death. Both ratios had acceptable sensitivities, specificities and positive predictive values. In this regard, A/B and C/D were comparable. The cut-off values for A/B and C/D were 4.3 and 4.52, respectively. Survivors had I significantly higher A/B and C/D ratios than non-survivors (P = 0.0001 and 0.0003, respectively). Significantly more fetuses with A/B or C/D below the established cut-off values had pulsations in the venous system (P < 0.05). In fetuses with a gestational age < =210 gestational days the survival rate was significantly higher in those with A/B or C/D above the cut-off values (P = 0.03 and 0.003, respectively).

CONCLUSIONS

The A/B or C/D ratio can be used for quantification of the reverse end-diastolic flow waveforms in the umbilical artery and may offer additional information to the evaluation of fetal condition.

Early screening for fetal cardiac anomalies by transvaginal echocardiography in an unselected population: the role of operator experience

OBJECTIVES

To examine the accuracy of early transvaginal fetal echocardiography performed in an unselected population by operators with different levels of experience and to compare the results with those obtained from a referral population.

DESIGN

Prospective study.

METHODS

A series of 4785 unselected fetuses and 221 referred fetuses were screened at 13-15 weeks' gestational age by transvaginal echocardiography. For each fetus, visualization of the four-chamber view plus the origin of the great arteries was attempted. Color Doppler imaging was only performed in cases of cardiac malformations already identified by two-dimensional echocardiography. The scans were performed by seven operators with different levels of experience. Reliability was assessed by conventional transabdominal echocardiography at 20-22 weeks, by postnatal follow-up in the first 3 months of life, and/or by autopsy in all cases of termination or fetal death.

RESULTS

The rate of complete visualization (four-chamber view plus great arteries) was 47.5% in the unselected population, and 76.9% in the referral population. There were four (0.08%) true positives among the unselected fetuses, and five (2.3%) among referrals, mostly with enlarged nuchal translucency or other malformations. Among the unselected fetuses, nine false negatives were detected by transabdominal echocardiography. Improvement in the operators' ability to recognize cardiac anomalies in unselected population was disappointing and was influenced more by individual approach than by the number of examinations performed.

CONCLUSIONS

Early screening for cardiac anomalies among unselected fetuses is ill-advisable. The usefulness of an early approach is confirmed in high risk fetuses or in the presence of enlarged nuchal translucency when performed by expert operators.

Screening for fetal anomalies by ultrasound at 14 and 21 weeks

A prospective study of screening for fetal abnormalities and chromosomal defects was carried out by ultrasound examination at 13-15 weeks of gestation and 20-22 weeks; the first scan was performed transvaginally and the second transabdominally. During a 4-year period (1991-95), 3490 unselected consecutive pregnancies with a total of 3514 fetuses were examined. There were 21 chromosomally abnormal fetuses, including ten with trisomy 21, and, in 19 (90.5%), fetal defects were detected at the first and/or second ultrasound examination. The most effective marker for chromosomal defects was increased nuchal translucency thickness (> or = 4 mm) at the 13-15-week scan, which was present in seven of the ten fetuses with trisomy 21 and in six of the 11 with other chromosomal abnormalities.

[Conservative management of ectopic pregnancy]

BACKGROUND

The aim of this retrospective study was to analyze the safety and efficacy of the conservative approach in the management of ectopic pregnancy.

METHODS

Thirty-five women with a tubal ectopic pregnancy, from 1990 to 1995, were subdivided into 2 treatment groups. Inclusion criteria were the following: tubal diameter < 3 cm, free fluid < 100 ml, no embryo heart activity, haemodynamic stability. Desire of future fertility and informed consent were requested. Eighteen women were treated with a single intramuscular injection of methotrexate, whereas in 17 cases expectant management was adopted.

RESULTS

In the first group 2 cases required surgical treatment (resolution rate = 89%). In the second group no surgery was needed and spontaneous resolution was achieved in all cases (100%). In both groups the average resolution time was about 17 days. Serum hCG-beta levels were monitored daily until resolution. The initial hCG-beta value and its following trend seem to be the most important prognostic factors.

CONCLUSIONS

More studies are indeed needed to establish the effect of conservative management on fertility after ectopic pregnancy.

[The indications for the management of fetuses with choroid plexus cysts]

Choroid plexus cysts (CPC) in the fetus are still the subject of considerable debate in the literature. Because of their association with aneuploidy, and especially with trisomy 18, of which they are an ultrasonographic marker, the detection of fetal CPC now poses the problem of how these cases should be managed, since most occur in young women (there being no correlation between CPC and age), and since the incidence among the general population is fairly high (around 1%). With the aim of contributing further to the debate, a retrospective study was performed of all cases of fetal CPC diagnosed in our Centre between January 1984 and August 1994, together with a review of the relevant literature. There were 95 cases of fetal CPC with complete neonatal and necroptic data available. These cases included women recruited in the course of routine screening for congenital malformations carried out in our Centre at 14 and 21 weeks gestation, women referred to us from other Centres, and women recruited in the course of amniocentesis indicated for those aged over 35. In all cases in which fetal CPC was detected, a careful ultrasonographic examination was performed to exclude the presence of even the smallest morphologic anomaly. Whenever the fetus was found to have an anomaly karyotyping was done. If the CPC was not associated with any morphologic anomaly, karyotyping was proposed only to those women at risk of aneuploidy because of their age. There were 11 cases of trisomy 18, all of which presented morphologic anomalies associated with CPC. Some of these anomalies where "minor", however, and therefore difficult to assess even when a careful ultrasonographic examination was performed by an experienced operator (Intra ventricular septal defect, single umbilical artery). In 2 cases, CPC was associated with trisomy 21. Both women were aged over 35. All the other cases of CPC not associated with morphologic anomaly were normal on postnatal examination. From a meta-analysis of the literature, two distinct management protocols emerge for the problem of "isolated CPC detected at ultrasonographic examination". One group of authors recommends karyotyping for all women with fetal CPC, considering the presence of CPC in itself a risk factor for aneuploidy. The second group, to which we ourselves belong, believes it is sufficient to perform a careful ultrasonographic examination so as to exclude the presence of other morphologic anomalies associated with the CPC. Karyotyping should be proposed only to women at risk of aneuploidy because of their age (> 35). A review of the biggest series reported in the literature shows that, of a total of 1670 fetuses with CPC, 94 were trisomy 18. None of the cases of CPC "in isolation" emerged as being associated with this aneuploidy. However, numerous cases of trisomy 18 have been described in which CPC is associated with "minor" morphologic anomalies in the fetus which may be difficult to detect. It is therefore essential to perform a careful ultrasonographic examination in all cases of CPC, preferably in a Centre with specialist knowledge of ultrasonography. If this option is not available, then karyotyping of all women with fetal CPC is clearly advisable.

Fetal blood sampling in labor

Cardiotocography is the most widely used method to monitor fetal well-being during labor. It has been shown that this technology is affected by a large intra and interobserver variability, that reduces its reliability. Moreover, it should be remembered that CTG is in condition to detect early fetal heart rate patterns that may indicate fetal hypoxaemia but it is not able to assess precisely the level of fetal compromise. This assessment can be done by examining fetal blood for pH that can be easily obtained in labor. If present, the level of acidemia, is established by measuring the pH which can be of practical use in clinical management. Values above 7.24 are considered normal, and pH values lower than 7.20 are expression of fetal acidemia requiring a quick delivery. The technique of FBS can be easily performed with very few complications. The main indication is one of the abnormal or suspicious CTG patterns. By using FBS is a complementary diagnostic tool to CTG it is possible to reduce the number of false positive thus reducing the number of unnecessary obstetrical interventions.

Computerized evaluation of fetal heart-rate patterns

Antepartum Cardiotocography (CTG) is one of the few techniques available today to assess fetal conditions in high risk pregnancies. Visual interpretation of CTG traces has been shown to be unreliable. In order to eliminate observer variability and to increase the accuracy of CTG, numerical on-line analysis of fetal heart rate (FHR) patterns was introduced. The experience with computerized systems has shown that the best indicator of fetal conditions is variation, long- or short-term. Mean range (Long-term variation) values of less than 20 msec are associated with an increased rate of fetal acidaemia and perinatal mortality. The availability of numerical measurements enables the detection of small changes in FHR occurring in time, so when initial deterioration signs arise, the single fetus can be followed up longitudinally. Moreover, a more accurate correlation with other biophysical and biochemical parameters of the fetus can be done, as well as with perinatal outcome. In conclusion, computerized CTG improves accuracy and allows to distinguish fetuses that are truly jeopardized because of hypoxemia, from those who are not.

The clinical significance of absent or reverse end-diastolic flow in the fetal aorta and umbilical artery

The clinical utility of Doppler blood flow investigations of the fetal and fetoplacental vessels is still under debate as far as timing of the delivery is concerned. However, in cases of absent or reverse end-diastolic flow, fetal compromise is usually very severe. As a consequence, we have investigated the possibility of using this information as a guide to obstetrical management. Altogether, 32 fetuses with absent or reverse end-diastolic flow in the fetal descending aorta and/or umbilical artery were studied. Reverse flow was observed in 11 cases and absence of end-diastolic flow in 21 cases. The two groups are considered separately. No significant difference was found in the mean gestational age at delivery. However, a highly significant difference was found in the mean birth weight and perinatal mortality rate. All the cases of perinatal mortality were encountered in the group presenting with reverse flow (mortality rate, 63.6%). All the live fetuses were delivered by Cesarean section and no neonatal mortality was observed in this group. Two cases of handicap were observed, one in each group. In our experience, reverse flow indicates the necessity for immediate delivery if no other clinical contraindications are present. Absence of end-diastolic flow can be observed for longer periods without adverse outcome. Absence of end-diastolic flow always precedes the appearance of fetal distress. Therefore, we believe that, after exclusion of conditions such as fetal abnormalities or extreme prematurity, a planned delivery should be considered.

Fetal echocardiography: the role of the screening procedure

1841 pregnant women without any risk factor for heart malformation of the fetus underwent an echocardiographic screening at an average gestational age of 23 weeks. Seven cases of heart diseases were diagnosed (0.38%), of which one died in utero at 28 weeks and another one was interrupted. In four cases the karyotype was carried out prenatally, while in the remaining three it was performed only after birth. There were 11 false-negative (0.59%), mainly concerning anomalies of minor clinical significance. Within this group, two newborns with interatrial defect of the ostium secundum type appeared to be affected by trisomy 21. Therefore, the rate of congenital heart diseases in live births not at risk (0.86%) was in line with the data reported in paediatric literature. On the other hand, the association with chromosomal anomalies was surprisingly frequent (4 out of the 9 karyotypes performed were anomalous). Such finding should be verified by studying a larger non-selected population. However, a fetal karyotype should be offered, for its practical consequences, also in those cases of cardiac anomalies of lesser clinical significance.

Flow cytometric analysis of DNA content in cervical lesions

Flow cytometry is used to screen gynaecologic specimens for Cervical Intraepithelial Neoplasia (CIN) and its precancerous lesions, possibly associated with human papilloma virus (HPV), in order to investigate the role of aneuploidy as a biological marker in HPV and CIN lesions. A total of 299 cervical samples was collected by scraping and the cellular DNA content was measured using the propidium iodide staining procedure. Two groups of patients were studied; a group of 142 negative controls for cytology and groups of patients assigned to mild, moderate or severe dysplasia, carcinoma in situ diagnosed by histologic classification according to the Papanicolaou staining technique. Pathological samples showing an alteration of the DNA index or perturbation of the cellular phase S compartment ranged from 6.4% to 41.9%. Our results confirm those obtained by other authors and suggest the hypothesis that aneuploidy is present with permanence of viral DNA in early stages of carcinogenesis, which can be used as a marker in the transition from benign to malignant cells. This work is of potential interest for the possible follow-up of patients having condyloma and could aid the early diagnosis of cervical carcinoma.

Anatomic correlates of ultrasound prenatal diagnosis of urinary tract abnormalities

In 52 fetuses, in utero sonographic diagnosis of urinary tract malformations was correlated with their autoptic or surgical findings. 39 malformations were correctly diagnosed prenatally, although 5 other extrarenal-associated anomalies were not detected; 10 diagnoses were incomplete; in 3 cases the characteristics of malformations found at sonography turned out to be different at the post-mortem examination. The following factors impaired sonographic diagnoses: limited number of examinations, gestational age at the time of examination, nature of malformation and, above all, oligohydramnios (which is common in most urinary tract malformations). The correlations between renal malformations and karyotype anomalies are also discussed in relation to the higher incidence present in polymalformative syndromes.

[Infection of Chlamydia trachomatis and dysplasia lesions of the cervix uteri (CIN)]

With the aim of evaluating the correlation between dysplastic lesions of the uterine cervix associated or not with condylomatosis and Chlamydia T. infection, we carried out a serological study of anti-Chlamydia species-specific antibodies and a direct and/or a cultural investigation on a sample of 320 women who performed a Pap-test. The serological examination showed positivity (titer greater than or equal to 1:32) in 49 control subjects (with negative cytology) (23.7%); in 27 cases (43.5%) with actual diagnosis of condylomatosis/CIN associated or not with condylomatosis and in 28 cases (54.9%) with previous diagnosis of condylomatosis/CIN associated or not with condylomatosis. The cultural investigation did not show any significant difference among the groups above mentioned. Finally, the frequency of positive cases for anti-Chlamydia antibodies was estimated for each grade of actual or previous CIN: a greater frequency of positivity was noted in cases with CIN 3 (75%).

Feto-placental haemodynamics in growth retardation: a pulsed Doppler study

69 singleton pregnancies, with a diagnosis of intra-uterine growth retardation (IUGR) at ultrasound, were followed until delivery by pulsed Doppler evaluations in fetal thoracic descending aorta (DA) and umbilical artery (UA). Three haemodynamic groups were described according to flow characteristics expressed as the pulsatility index (PI) of the vessel under study. In each group the relative incidence of fetal distress, diagnosed according to CTG monitoring, was evaluated. Fetal distress occurred in 75% of the cases with a raised PI both in DA and UA, in 40% of the cases with a raised PI only in DA and in 21% of the cases with 'normal' PI values in both vessels. It can be said that Doppler flow measurements can be useful in defining the actual haemodynamic situation of the fetus with possible clarifications concerning its 'stressed' or 'distressed' condition and residual capacities to substain hypoxia.

Cervical dilatation by sulprostone prior to vacuum aspiration for termination of early pregnancy

In the period May 1983-October 1986 we treated 335 primigravidae requesting an abortion in the first trimester. They were given 500 micrograms sulprostone (16-phenoxy-omega-tetranor-PGE2-methylsulfonylamide) i.m. 12 to 14 hours before suction termination in order to obtain adequate and atraumatic cervical dilatation and thus reduce the possible risk of cervical incompetence and its consequences. The effects of this technique on the uterine cervix were compared with those obtained in 100 primigravidae after the insertion of laminaria to induce atraumatic cervical dilatation. We also evaluated the normal degree of cervical dilatation before any intervention in a control group of 100 primigravidae. The results obtained with sulprostone encourage the use of this drug to minimize cervical injury. The incidence of side-effects was not particularly high.

Management of intrauterine growth retardation: diagnostic and clinical aspects

A retrospective analysis of the ultrasonic charts of 150 pregnancies with a birth weight below the tenth percentile is presented. In all cases the first scan was carried out before the 20th week of gestation to assess gestational age measuring crown to rump length or biparietal diameter (BPD). Subsequent scans every 4 weeks measured BPD or abdominal circumference. Birth weight was below the fifth percentile in 70 cases and between the fifth and tenth percentiles in 80 cases. A risk condition was found in 32.26%. The first observation of an abnormal parameter was widely spread throughout the latter half of the pregnancy. The management of IUGR included close observation and often required planned delivery. Cesarean section was required in 30.75% of the cases. Acute fetal distress has been the indication in 17.6% of cases and chronic fetal distress in 41.3%. Perinatal mortality was 6.66%. The need for criteria that will accurately detect the fetus most at risk from complications of IUGR is stressed.

The validity of the atropine test

In order to evaluate the clinical validity of the so-called "atropine test", it has been performed in 83 women in their 35th to 43rd week of pregnancy. A statistical evaluation of the data has shown a serious limitation of both diagnostic and prognostic possibilities of the test; this can be attributed to the great variability of maternal environments.

Further evaluation of quinestrol in the inhibition of lactation: a double-blind comparison of two dose levels against placebo

One hundred and ninetysix post-partum women, in whom lactation was to be prevented, were given under double-blind conditions either placebo or quinestrol 2 mg or 4 mg as a single oral dose within twentyfour hours of delivery. Early assessment of the results gave a failure rate of 58 per cent, 15 per cent and 5 per cent respectively, with statistically significant differences among the three groups of patients. At the follow-up evaluation, which could be made in only about one third of the women, breast troubles were recorded in 20 to 30 per cent, without significant differences among the groups. Post-partum amenorrhea showed a progressive prolongation from an average of 47.9 days in the controls to 64.6 and 72.6 days respectively in the 2 and 4 mg quinestrol groups. Adverse reactions, represented by delayed uterine involution during hospital stay and abnormal uterine bleeding in the late puerperium, were somewhat more frequent in the higher dose group than in the lower dose and control groups. On the basis of the prsent findings and of similar, though rare, experiences reported in the relevant literature, the question is therefore raised whether the 2 mg quinestrol dose would not be preferable to the 4 mg one for routine use in post-partum nonusing women.