Relationship Between Maternal Bone Biomarkers and Fetal Adiposity Through Normal Pregnancy

PURPOSE

To examine the association of maternal bone markers [sclerostin, soluble receptor activator of nuclear factor-κB ligand (sRANKL), osteocalcin, 25-hydroxyvitamin D3] with fetal intra-abdominal and subcutaneous adipose tissue deposition and birthweight during normal pregnancy.

METHODS

One hundred pregnant women (aged 30.4 ± 5.6 years, mean ± SD) with prepregnancy body mass index = 24.1 ± 4.6 kg/m2 were seen prospectively during each trimester. At each visit they were submitted to anthropometric measurements, a fasting blood sampling, a 75-g oral glucose tolerance test, and a fetal ultrasonogram. At birth, neonates had birth weight measurement.

RESULTS

In the second trimester, maternal sclerostin concentrations correlated positively with fetal abdominal circumference and birth weight; maternal sRANKL concentrations correlated positively with fetal abdominal subcutaneous fat thickness, sagittal abdominal diameter, and abdominal circumference. Fetuses born to mothers with greater (>254 ng/mL), compared to fetuses born to mothers with lower (≤254ng/mL), sRANKL concentrations had greater abdominal circumference, sagittal diameter, and abdominal subcutaneous fat thickness. Maternal serum sclerostin concentrations were the best positive predictors of birth weight. In the third trimester maternal sclerostin concentrations correlated positively with fetal sagittal abdominal diameter; maternal sRANKL concentrations positively correlated with fetal abdominal circumference and fetal abdominal sagittal diameter.

CONCLUSIONS

Maternal bone markers sclerostin and sRANKL may relate to fetal intra-abdominal adipose tissue deposition through as yet unknown direct or indirect mechanisms, thus contributing to birthweight.

Counselling for smoking cessation during pregnancy reduces tobacco-specific nitrosamine (NNAL) concentrations: A randomized controlled trial

INTRODUCTION

Smoking cessation during pregnancy is beneficial to both the mother and child. Our objective was to assess if an intensive smoking cessation intervention for pregnant women increases: a) rates of smoking cessation, and b) reduces exposure to tobacco-specific carcinogens during pregnancy.

METHODS

A two-group single-blinded parallel randomized controlled trial (RCT) was conducted involving 84 pregnant smokers in either a high intensity (n=42) or minimal contact control group (n=42). Women assigned to the high intensity smoking cessation intervention group received a single 30-minute behavioural counselling session and a tailored self-help booklet. The primary outcome measures were: 7-day point prevalence abstinence measured by selfreport and urine cotinine levels, and maternal tobacco specific carcinogens nitrosamine (NNAL) urine concentrations assessed at 32 weeks of gestation.

RESULTS

A significantly greater percentage of pregnant smokers quit smoking in the high intensity group compared to the low intensity control group (45.2% vs 21.4%; p=0.001). A significant decrease in urine cotinine concentrations was documented in the experimental group (-140.74 ± 361.70 ng/mL; p=0.004), with no significant decrease documented in the control group. A significant decrease in NNAL levels was also documented in the experimental group (158.17 ± 145.03 pg/mL before, 86.43 ± 112.54 pg/mL after; p=0.032) with no significant changes in the control group.

CONCLUSIONS

The high intensity intervention tested resulted in significantly greater cessation rates. Intensive smoking cessation interventions can be effective in reducing fetal exposure to NNAL. This is the first trial to report on NNAL tobacco-specific carcinogen concentrations before and after an intervention for smoking cessation during pregnancy.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01210118.

ABBREVIATIONS

5Αs: ask, advise, asses, assist, arrange; GHQ: general health questionnaire; ANOVA: analysis of variance; RCT: randomized control trials; NNAL: 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol.

Homeopathy for infertility treatment: a case series

Homeopathy has been used in the past for treating a broad aspect of diseases. In gynecology, its use remains limited. Taking under consideration its clinical aspects, the authors attempted to use it for treating female sub fertility problems. With this study, the authors present five cases of female infertility treated successfully with the use of homeopathic treatment in a large obstetrics-gynecology Hospital in Athens.

Corticotropin-releasing hormone and progesterone plasma levels association with the onset and progression of labor

PURPOSE OF LNVESTIGATION: To examine the relationship between maternal plasma progesterone along with corticotropin- releasing hormone (CRH) plasma levels and the progression of labor.

MATERIALS AND METHODS

Maternal serum CRH and progesterone were measured during the latent phase of labor, active labor, and 24 hours postpartum in women who went into spontaneous labor and delivered vaginally at term. Progesterone (P) levels in women delivered by an elective cesarean section at term were also measured as baseline.

RESULTS

Mean maternal plasma P was 18% higher in the active phase than in the latent phase of labor (p < 0.01), and declined significantly by 24 hours postpartum (p < 0.001). Mean level of serum CRH was 24% higher in the active phase than in the latent phase of labor (p < 0.01), and subsequently declined significantly by 24 hours postpartum (p < 0.001).

CONCLUSIONS

As labor progresses, P and CRH increase and subsequently decrease precipitously in the immediate postpartal period. P levels tend to drop in women who are in early labor compared with non-laboring full-term women.

Design and study protocol of the maternal smoking cessation during pregnancy study, (M-SCOPE)

BACKGROUND

Maternal smoking is the most significant cause of preventable complications during pregnancy, with smoking cessation during pregnancy shown to increase birth weight and reduce preterm birth among pregnant women who quit smoking. Taking into account the fact that the number of women who smoke in Greece has increased steadily throughout the previous decade and that the prevalence of smoking among Greek females is one of the highest in the world, smoking cessation should be a top priority among Greek health care professionals.

METHODS/DESIGN

The Maternal Smoking Cessation during Pregnancy Study (M-SCOPE), is a Randomized Control Trial (RCT) that aims to test whether offering Greek pregnant smokers a high intensity intervention increases smoking cessation during the third trimester of pregnancy, when compared to a low intensity intervention. Prospective participants will be pregnant smokers of more than 5 cigarettes per week, recruited up to the second trimester of pregnancy. Urine samples for biomarker analysis of cotinine will be collected at three time points: at baseline, at around the 32nd week of gestation and at six months post partum. The control group/low intensity intervention will include: brief advice for 5 minutes and a short leaflet, while the experimental group/intensive intervention will include: 30 minutes of individualized cognitive-behavioural intervention provided by a trained health professional and a self-help manual especially tailored for smoking cessation during pregnancy, while counselling will be based on the ''5 As.'' After childbirth, the infants' birth weight, gestational age and any other health related complications during pregnancy will be recorded. A six months post-partum a follow up will be performed in order to re-assess the quitters smoking status.

DISCUSSION

If offering pregnant smokers a high intensity intervention for smoking cessation increases the rate of smoking cessation in comparison to a usual care low intensity intervention in Greek pregnant smokers, such a scheme if beneficial could be implemented successfully within clinical practice in Greece.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT01210118.

Asynchronous delivery of twins and triplets with an interval period ranging from 48 hours to 19 weeks

OBJECTIVE

To improve perinatal survival rates by prolonging the rest of the pregnancy after an abortion or extremely premature birth of one fetus in multiple pregnancies, especially in women with low fertility potential.

METHODS

Following the expulsion of one fetus a cervical cerclage was applied to all patients. The placenta of the expelled fetus including a small portion of its cord after it was ligated close to the external os, was left in situ. The patients were invariably kept on bed rest until the pregnancy was completed under close observation, tocolysis and preventive antibiosis. After the 24th week of gestation corticosteroids were administered.

RESULTS

The delivery interval achieved ranged between two and 135 days, the longest reported. Although the survival rate was relatively low (40%) all but one of the women (83%) managed eventually to have a live child, one with twins.

CONCLUSIONS

In selected multiple pregnancies the attempt to prolong the rest or the pregnancy, following the abortion or the extremely premature birth of one fetus, seems efficacious and justified especially in women with a history of long-term infertility.

Uterine artery Doppler velocimetry with leiomyomas

The study was conducted to establish a correlation between Doppler velocimetry in relation to uterine weight in any phase of the menstrual cycle and symptoms in women who have leiomyomas. Doppler velocimetry was carried out on both uterine arteries in 18 pre-menopausal women and one post-menopausal woman prior to undergoing abdominal hysterectomy at Winthrop University Hospital in Mineola, NY and at Ioannina University Hospital. The t-test was used for statistical analysis. Changes in flow velocity correlated directly with uterine size. When a division at 500 g was used, S/D ratio was 2.74 +/- 0.53 for larger uteri vs. 4.2 +/- 1.24 for smaller uteri, p < 0.006. Eight women presented heavy bleeding and the mean S/D ratio was 3.75 +/- 1.36 while eleven women presented mild bleeding and the mean S/D ratio was 3.51 +/- 1.2 (p > 0.5). Thus the study has demonstrated that in cases of uterine leiomyomas, the uterine artery flow increases although angiography had previously shown decreased vascularity within the tumor.

Comparison of somatomedin-C (SMC/IGF-I), human placental lactogen and Doppler velocimetry between appropriate and small-for-gestational-age pregnancies

Thirty-two pregnant women with small-for-gestational-age (SGA) fetuses and 45 pregnant women with appropriate-for-gestional-age (AGA) fetuses (controls) were recruited after the 32nd week of gestation. Blood samples were collected for estimation of somatomedin-C (SMC/IGF-I) and hPL in the maternal serum and in the umbilical cord serum. The systolic/diastolic (S/D) ratio of the umbilical artery was also recorded. The results showed somatomedin-C and hPL levels in the maternal serum and in the umbilical cord to be significantly decreased and the Doppler S/D ratio to be significantly increased in the SGA group. In this group, using the multivariable regression analysis, we found significant correlations between maternal hPL, somatomedin-C, Doppler S/D ratio and birth weight.

Fetal heart rate patterns in pregnancies complicated by maternal diabetes

OBJECTIVE

To compare the fetal heart rate (FHR) pattern between fetuses of well controlled diabetic and non diabetic mothers using a computerized analysis of FHR.

STUDY DESIGN

Weekly fetal surveillance was performed in 99 fetuses of mothers with diabetes class A, 21 fetuses of mothers with diabetes class B-R, and 55 fetuses of non-diabetic women, starting at 30 weeks' gestation. All diabetic patients were well controlled. Fetal surveillance included a computerized analysis of the FHR, umbilical and uterine Doppler velocimetry, and a biophysical profile. Changes of FHR variation, frequency of FHR accelerations, and umbilical and uterine Doppler velocimetry were calculated using a regression analysis for each patient. The average slopes and the intercept at 30, 34, and 38 weeks' gestation of these variables were compared among the three groups.

RESULTS

The slope of FHR variation and the frequency of accelerations had a lower rate of increase during the third trimester in fetuses of mothers with diabetes class A (0.84 +/- 0.25 ms/week and 0.06 +/- 0.02/20 min/week, respectively) compared with fetuses of non-diabetic mothers (1.34 +/- 0.55 ms/week and 0.5 +/- 0.1/20 min/week, respectively). In fetuses of mothers with diabetes class B-R, FHR variation did not change with gestation (-0.011 +/- 0.2 ms/week) with a small increase in the frequency of accelerations (0.02 +/- 0.004/20 min/week). While no differences were observed at 30 weeks' gestation, FHR variation and the frequency of accelerations were significantly reduced at 34 weeks' gestation in fetuses of mothers with diabetes class B-R compared with fetuses of non-diabetic mothers (P < 0.01). At 38 weeks' gestation, fetuses of mothers with diabetes class B-R and diabetes class A had both significantly reduced FHR variation as well as frequency of accelerations compared with fetuses of non-diabetic mothers (P < 0.01). The rate of decrease of the umbilical and uterine artery S/D ratios were similar among the three groups.

CONCLUSIONS

The FHR pattern appears to be different in fetuses of well controlled diabetic mothers when related to fetuses of non-diabetic mothers. Disease specific standards should be considered for interpretation of FHR patterns in diabetic pregnancies.

Computerized analysis of fetal heart rate changes after antepartum external cephalic version

OBJECTIVE

To assess the fetal heart rate (FHR) changes following external cephalic version using a computerized FHR monitor.

STUDY DESIGN

We performed 116 external cephalic versions on 106 pregnant women at 36-40 weeks' gestation. Tocolysis (magnesium sulfate) was given to 39 patients (34%). Computerized FHR monitoring was performed for 20-30 minutes before and for 20-30 minutes after the procedure. In addition, we analyzed the results of the FHR tracing obtained during the first 10 minutes following the procedure.

RESULTS

External cephalic version was successful in 40% of the patients. In the group of patients who were not treated with magnesium sulfate, FHR variation and the number of accelerations per 10 minutes were significantly reduced during the first 10 minutes following the procedure as compared with those factors on the FHR tracings obtained before or 20-30 minutes following the procedure (P < .05). In the group of patients who were treated with magnesium sulfate, FHR variation and the number of accelerations per 10 minutes were significantly reduced before and 10 minutes after the procedure as compared with the FHR tracings obtained 20-30 minutes following the procedure (P < .05). In both groups the basal FHR was significantly lower during the first 20-30 minutes following the procedure (P < .05). FHR decelerations were observed following the procedure in only two patients. None of the 106 fetuses had a low Apgar score or were admitted to the neonatal intensive care unit.

CONCLUSION

External cephalic version appears to be safe for the mother and fetus, although transient FHR changes may occur following the procedure.

Doppler study of the fetal cardiac function in prolonged pregnancies

OBJECTIVE

To evaluate the association between fetal cardiac function and amniotic fluid index (AFI) in postterm fetuses, and to determine if changes in fetal cardiac function precede the occurrence of nonreassuring intrapartum fetal heart rate (FHR) patterns.

METHODS

Forty-five otherwise low-risk pregnant women between 41 and 43 weeks' gestation were studied longitudinally. Gestational age was confirmed in all patients by ultrasound before 20 weeks' gestation. Each subject had two or three tests performed every 3-4 days, including a non-stress test, a biophysical profile, and Doppler studies of the aortic and pulmonic outflow tracts. Aortic and pulmonic artery flow velocity waveforms were recorded slightly distal to the valves. Peak velocity, velocity time integral, and heart rate were calculated from the flow velocity waveforms we obtained. The change in AFI and aortic and pulmonic peak velocity and [velocity time integral] x [heart rate] were calculated for each fetus.

RESULTS

Labor was induced at 42 weeks' gestation in 20 patients, and 17 entered labor spontaneously. Changes in AFI, observed during the follow-up period, correlated significantly with changes in aortic peak velocity (r = 0.54, P < .01) and with aortic outflow [velocity time integral] x [heart rate] (r = 0.60, P < .001) but not with pulmonic peak velocity and [velocity time integral] x [heart rate]. The decrease in aortic peak velocity and aortic and pulmonic [velocity time integral] x [heart rate] was significantly higher (P < .01) in eight fetuses that developed a nonreassuring intrapartum FHR (reduced FHR variability, late decelerations, and severe variable decelerations) than in those who had an uneventful labor.

CONCLUSION

In prolonged pregnancies, cardiac function deteriorates in fetuses that develop a nonreassuring intrapartum FHR, and the changes in the left cardiac function correlate with changes in AFI.

Central and peripheral haemodynamic changes in post-term fetuses: correlation with oligohydramnios and abnormal fetal heart rate pattern

OBJECTIVE

To assess the hypothesis that the occurrence of oligohydramnios and abnormal fetal heart rate (FHR) pattern in post-term fetuses is associated with impaired fetal cardiac function.

DESIGN

A cross sectional study was performed on post-term and term fetuses. Fetal tests included a computerised analysis of the FHR, a biophysical profile and Doppler studies of the abdominal aorta, umbilical artery, middle cerebral artery and the fetal heart. Pulsatility index (PI) was calculated from the abdominal aorta, umbilical and middle cerebral artery flow velocity waveforms. Peak velocity, velocity time integral (VTI), E:A ratio, and heart rate (HR) were calculated from the flow velocity waveforms obtained from the aortic and pulmonic outflow, and from the mitral and tricuspid valves.

SETTING

Maternal fetal laboratory, Department of Obstetrics.

SAMPLE

One hundred and twenty post-term and 42 term fetuses.

RESULTS

Only the tricuspid E:A ratio was significantly higher (P < 0.05) in post-term fetuses with a normal amniotic fluid index compared with term fetuses. Post-term fetuses with an abnormal amniotic fluid index had a significantly lower aortic peak velocity (P < 0.01), aortic VTI x HR (P < 0.01), and mitral VTI x HR (P < 0.05) compared with post-term fetuses with a normal amniotic fluid index or compared with term fetuses. Post-term fetuses with reduced FHR variation had a significantly lower aortic peak velocity (P < 0.01), pulmonic peak velocity (P < 0.05), aortic VTI x HR (P < 0.01), pulmonic VTI x HR (P < 0.05) and a significantly lower mitral VTI x HR (P < 0.05) when compared with post-term fetuses with normal FHR variation. Similar results were obtained in comparing fetuses with normal and adverse perinatal outcome.

CONCLUSION

The occurrence of oligohydramnios and abnormal FHR pattern in post-term fetuses appears to be associated with impaired fetal cardiac function. This finding should allow further investigations of post-term fetuses.

Surveillance of growth-retarded fetuses with computerized fetal heart rate monitoring combined with Doppler velocimetry of the umbilical and uterine arteries

OBJECTIVE

To define guidelines for surveillance of growth-retarded fetuses with a computerized fetal heart rate (FHR) monitor and Doppler device.

STUDY DESIGN

Eighty-one growth-retarded fetuses with birth weights < 10th percentile and lacking major anomalies were studied. One hundred ninety-two tests (one to six per patient), including computerized FHR monitoring and Doppler studies of the umbilical and uterine arteries, were performed. The relationship between Doppler velocimetry or FHR variation and fetal outcome was examined.

RESULTS

Fetuses with an abnormal FHR variation or abnormal Doppler velocimetry had a significantly higher rate of cesarean deliveries for fetal distress and a higher number of admissions to the neonatal intensive care unit (NICU) as compared with fetuses with normal results on both tests. The best distinction was noted when the growth-retarded fetuses were partitioned into four analytic groups based on the presence of normal or abnormal FHR variation or Doppler velocimetry. The group with the poorest results was composed of fetuses with abnormal umbilical flow velocity and reduced FHR variation. These fetuses had significantly lower birth weights (1,250 g) and significantly higher rates of cesarean deliveries for fetal distress (92%) and admission to the NICU (100%). Thirty percent of these fetuses died.

CONCLUSION

Fetal surveillance with Doppler and computerized FHR monitoring allows better understanding of the management of fetuses that are small for gestational age.

Elevated umbilical erythropoietin levels during labor in newborns of smoking mothers

Umbilical cord blood erythropoietin levels and hematocrit are significantly higher in smoking mothers than those nonsmoking ones. In addition, the incidence of newborns with low birthweight is higher in women who smoke. We conclude that in addition to other parameters, cord blood erythropoietin might be used as a valuable indicator of fetal distress in smokers.

Successful pregnancy after treatment of cervical pregnancy with methotrexate and curettage. A case report

Cervical pregnancy was diagnosed in a nulliparous, 28-year-old woman who presented with intermittent vaginal spotting at 12 weeks of gestation. Sonographic evaluation revealed a cervical gestational sac with a fetus with cardiac activity. Methotrexate was instilled intraamniotically, followed by an intramuscular injection with folinic acid rescue. On the seventh day of treatment an uneventful curettage was performed because of persistent fetal viability. Five months later pregnancy occurred. The patient vaginally delivered a healthy, 3,080-g neonate at 40 weeks of gestation. To our knowledge, only nine other cervical pregnancies have been managed medically with either methotrexate or etoposide. It seems that first-trimester cervical pregnancies, especially those at less than nine weeks of gestation, can be effectively treated with methotrexate. Successful medical therapy must be considered, not only for regression of the gestation but also for preservation of anatomic integrity and fertility. Four of the above patients, including ours, had a subsequent intrauterine pregnancy, and one of those pregnancies terminated in spontaneous abortion.

Corpus luteum blood flow in normal and abnormal early pregnancy: evaluation with transvaginal color and pulsed Doppler sonography

One hundred and thirteen (66.5%) women in this study had a normal intrauterine pregnancy with ages ranging 6 to 12 weeks of gestation. Fifty-seven (33.5%) patients were admitted to the hospital owing to clinically suspected abnormal early pregnancy. Dilatation and curettage were done on all women and tissue sample sent to the pathologist for a final diagnostic. Diagnosis of ectopic pregnancy was made on laparoscopy. Both ovaries were examined carefully by color Doppler in sonography in all patients. Color flow was used as a guide for pulsed Doppler exploration. Corpus luteum blood flow was defined as random, usually semilunar in appearance, dispersed vessels with very low impedance to blood flow. The resistive index and pulsatility index were calculated. Overall detection rate of corpus luteum blood flow in normal pregnancies was higher for the left ovary (62.6%) than for the right ovary (37.4%) (P < 0.01). The mean resistive and pulsatility indices from corpus luteum blood flow were not influenced by gestational age in normal pregnancy. The overall mean value for for resistive index was 0.452 +/- 0.04 and for pulsatility index 0.636 +/- 0.09. The overall detection rate of corpus luteum in abnormal pregnancies also was higher for the left ovary (56.7%) than for the right ovary (43.4%) (P < 0.01). The mean resistive indices from corpus luteum blood flow in patients with missed abortion was higher than in women with normal pregnancy (P < 0.01). Both resistive and pulsatility indices were higher in patients with incomplete or threatened abortion in comparison with normal pregnancy (P < 0.01). No statistically significant difference was seen in the case of anembryonic, molar, or ectopic pregnancy.

Doppler velocimetry. Where does it belong in evaluation of fetal status?

Doppler velocimetry is very useful as an antepartum surveillance tool that is able to detect pathologies of the fetus and predict the development of acidosis and hypoxia. Appropriate use can help us to decrease the mortality and morbidity in identifying earlier compromised fetuses.

Erythropoietin umbilical serum levels during labor in women with preeclampsia, diabetes, and preterm labor

In this study we determine the erythropoietin levels and hematocrit in 22 women with preterm labor, 21 with insulin-dependent diabetes, 22 with preeclampsia, and 20 with normal gestation. The erythropoietin level was higher in the preeclamptic group than in the diabetic group compared with the normal and premature groups. There were no hypoxic fetuses. From this study, we found that the mechanism of increased erythropoietin levels in neonates can be different from fetal hypoxia. Further studies are needed on this subject.

Computerized analysis of fetal heart rate variation in postterm pregnancy: prediction of intrapartum fetal distress and fetal acidosis

OBJECTIVE

Our purpose was to evaluate whether computerized analysis of fetal heart rate variation may improve fetal surveillance in postterm pregnancy.

STUDY DESIGN

Three hundred thirty-seven pregnant women who were delivered after 41 weeks' gestation and who had 610 antenatal tests were included in this study. Fetal tests included a nonstress test with a computerized analysis of the fetal heart rate, Doppler examination of the umbilical artery, and a biophysical profile, performed every 2 to 4 days. Induction of labor was performed when the fetal heart rate variation was reduced (< 30 msec), when fetal heart rate decelerations appeared, or when the amniotic fluid index was < or = 5. The results of the fetal surveillance tests were compared with the results of the intrapartum fetal heart rate monitoring and with the metabolic status of the babies at delivery. Sensitivity and specificity of the various tests in predicting intrapartum fetal distress and acidosis at delivery were described by means of the receiver-operator characteristic curve.

RESULTS

Ten of 12 fetuses with reduced fetal heart rate variation had a trial of labor. Nine of these 10 fetuses had fetal distress during labor. Seven of the 12 fetuses with reduced fetal heart rate variation were acidotic at delivery (umbilical artery pH < 7.2). Overall, there were 10 acidotic fetuses at delivery in the study group. Only two of them had an umbilical systolic/diastolic ratio > 95th percentile, three had an amniotic fluid index < or = 5, and five had fetal heart rate decelerations before labor. Fetuses who demonstrated an abnormal intrapartum fetal heart rate tracing or who were acidotic at delivery had a significantly higher rate of reduced fetal heart rate variation or decelerations before labor. The largest area under the receiver-operator curve curve for predicting fetal acidosis at delivery or fetal distress during labor was achieved by means of computerized analysis of fetal heart rate variation.

CONCLUSION

A computerized numeric analysis of fetal heart rate variation may improve fetal surveillance in postterm pregnancy.

Prevalence in a volunteer population of pelvic cancer detected with transvaginal ultrasound and color flow Doppler

Our objective was to find the prevalence of non-symptomatic endometrial and ovarian neoplasms in a volunteer population of women, aged 40 and over. We offered a free volunteer screening program to asymptomatic women for a study using transvaginal ultrasound and color flow Doppler for the detection of pelvic cancer. In the first 2 years, 2117 women were examined, 51.3% post-menopausal. An ovarian cyst was defined as having a maximum diameter of more than 2.4 cm. Color flow was used to identify blood vessels feeding pelvic organs and adnexal enlargements. An abnormal Doppler flow velocity for the ovary was defined as a resistance index of less than 0.41. Ovarian cysts of less than 5 cm with normal Doppler indices were followed up in 6 months to 1 year. An adnexal morphology score was created to quantify the usefulness of this parameter, particularly in postmenopausal women. Indications for surgery were pre-defined as a persistent ovarian cyst of more than 5 cm, a persistent suspicious Doppler and a total endometrial thickness of greater than 0.59 cm in postmenopausal women not taking hormones.A total of 202 women (9.5%) had ovarian cysts. Fourteen women were operated upon because of size criteria, one because of family history and three for persistent abnormal flow. By Doppler study, 15 cysts were predicted to be benign and histology was confirmatory. There were two false positives and one true positive, a stage Ib ovarian cancer. There were no false negatives, although a stage I endometrioid cancer of the ovary was detected 8 months after a negative scan. In those cases in which follow-up data were available, 56% of the cysts regressed in premenopausal women. In postmenopausal women, 28% regressed. Twenty of 1086 postmenopausal women had endometrial biopsies. Three had endometrial cancer, two stage I and one stage IIA. Five had atypical or adenomatous hyperplasia, and seven had benign polyps. So many women have small asymptomatic cysts of the ovary that a major reorientation of physicians' attitudes towards the ovary will have to be introduced to adapt to this new information. In this population, the prevalence of benign epithelial ovarian neoplasms was 7/1000, and of malignancy was 05/1000. In postmenopausal women, the prevalence rate for endometrial cancer was 5/1000, with 5/1000 hyperplasias and 7/1000 benign polyps. When endometrial and ovarian cancer screening are combined, the yield is comparable to that seen in breast and cervical cancer screening.

Central and peripheral hemodynamic changes in fetuses with absent end-diastolic velocity in umbilical artery: correlation with computerized fetal heart rate pattern

OBJECTIVES

Our purpose was to study hemodynamic changes in peripheral and central blood vessels and to correlate these changes with the computerized fetal heart rate pattern in fetuses with absent end-diastolic velocity in the umbilical artery.

STUDY DESIGN

Doppler studies of the umbilical artery, the middle cerebral artery, and aortic and pulmonic outflow, together with computerized fetal heart rate monitoring, were performed every 2 to 4 days until delivery in 13 fetuses with absent end-diastolic velocity in the umbilical artery. The pulsatility index was calculated from the flow velocity waveforms obtained from the umbilical and middle cerebral arteries. The velocity time integral (an index of cardiac output) and the heart rate were calculated from the flow velocity waveforms obtained from the aortic and pulmonic outflow.

RESULTS

Two fetuses were delivered immediately after the first examination because of repetitive fetal heart rate decelerations. One fetus was excluded from the study because of major malformations. Ten had three to eight tests each. Six had a biphasic change of the middle cerebral artery, which consisted of a decrease (p < 0.001) followed by an increase in the pulsatility index (p < 0.05). When the middle cerebral artery lost its vasodilation, there was an increase in the middle cerebral artery/umbilical artery pulsatility index ratio (p < 0.05). Left cardiac output decreased (p < 0.05), resulting in an increase in the pulmonary/aortic velocity time integral x heart rate ratio (p < 0.05). Reduced fetal heart rate variation (< 30 msec) developed in all six fetuses, and they were delivered because of repetitive fetal heart rate decelerations. Four fetuses with only a decrease in the middle cerebral artery pulsatility index did not have reduced fetal heart rate variation or decelerations, the aortic velocity time integral x heart rate didn't decrease, and the pulmonic/aortic velocity time integral x heart rate ratio didn't increase. These fetuses were delivered for reasons other than fetal distress. The middle cerebral artery pulsatility index correlated with the aortic velocity time integral x heart rate (r = -0.53, p < 0.0001), and the middle cerebral artery/umbilical artery pulsatility index correlated with the pulmonic/aortic velocity time integral x heart rate (r = 0.56, p < 0.0001).

CONCLUSION

Abnormal fetal heart rate patterns occur in fetuses with absent end-diastolic velocity in the umbilical artery when the middle cerebral artery begins to lose its compensatory maximal dilation. The increase in the middle cerebral artery pulsatility index is associated with a significant reduction in left ventricular output without significant changes in right ventricular function. Thus it appears that a loss of autonomic reactivity occurs in the brain first and is followed within a few days by a similar response in the heart, as shown by the decreased fetal heart rate variation.

Urinary and amniotic epidermal growth factor during normal and abnormal pregnancies. A comparison based upon umbilical Doppler velocimetry

Fetal growth retardation is associated with abnormal umbilical flow velocity. We have begun a systematic study of growth factors and their relationship to this specific pattern of growth retardation. Using a specific double-antibody epidermal growth factor (EGF) 125I-radioimmunoassay, we studied urinary EGF in normal pregnancy from 5 to 42 weeks of gestation, and amniotic fluid EGF from 18 to 24 weeks. EGF levels increased from early pregnancy until 21-28 weeks, when they declined to a level at term similar to non-pregnant controls and first-trimester pregnancy levels. There was no significant difference in urinary EGF levels between women delivering appropriate-for-gestational-age (AGA) infants, and those delivering small-for-gestational-age infants (SGA). We conclude that the urinary EGF is not different in the SGA pregnancy from normal pregnancy.

Diagnosis of intrauterine growth retardation as a two-step process with morphometric ultrasound and Doppler umbilical artery velocimetry

Ultrasound and Doppler umbilical artery velocimetry have been used to diagnose the small-for-gestational-age (SGA) fetus. Both techniques are relatively inefficient for this diagnosis. The aim of the present study was to see whether their serial use improved diagnostic accuracy. Forty women with an ultrasound diagnosis of SGA within three weeks of delivery were studied with velocimetry, and the outcome was evaluated. Diagnostic accuracy was improved from 65% by ultrasonography alone to 92% by the addition of an abnormal umbilical artery waveform (P < .02). An abnormal waveform was associated with an adverse outcome in 62%, compared to 14% with normal velocimetry (P < .01). The majority of small fetuses have a normal outcome. The combination of ultrasonography and velocimetry improved diagnostic accuracy and identified those small fetuses truly at risk.

Umbilical and uterine artery flow velocity waveforms in normal pregnancy and pregnancy induced hypertension

Umbilical and uterine artery Doppler studies were carried out in 113 cases of normal pregnancy and in 32 patients with pregnancy induced hypertension (PIH). The results were analyzed by calculating the systolic/diastolic (S/D) ratio. In normal pregnancy the umbilical velocity wave S/D ratio declined from 3.9 to 2.1 from 20th week to term, and the uterine wave S/D ratio remained constant between 1.8 and 1.9. In many cases of severe PIH the umbilical and uterine artery velocity wave S/D ratios were raised, indicating increased resistance to the blood flow. The changes of umbilical waveforms appeared earlier than those of the uterine arterial waveforms.

Significance of umbilical and uterine artery velocimetry in the well-controlled pregnant diabetic

The measurement of umbilical and uterine artery velocity waveforms was used to study pregnancies complicated by diabetes. Continuous wave Doppler velocimetry was used to identify the umbilical and uterine artery velocity waveforms. A systolic:end diastolic ratio (S:D ratio) was calculated to analyze the obtained velocity waveforms. We treated 33 tightly controlled and monitored diabetic gravidas. The mean blood sugar value for this population was 95 +/- 8 mg/dL, and the mean umbilical artery S:D ratio was 2.5 +/- 0.3. That group of patients was compared to a group on which we reported previously. Statistically significant differences were found between the well-controlled and poorly controlled populations in third-trimester S:D ratios, number of stillbirths and neonatal morbidity. Uterine artery velocimetry allowed the identification of a patient who developed preeclampsia. This study seems to have indicated that umbilical and uterine artery velocimetry may have an adjunctive role in the surveillance of pregnancies complicated by diabetes.

Pregnancy surveillance with Doppler velocimetry of uterine and umbilical arteries

Previous studies with Doppler velocimetry have demonstrated a strong correlation between abnormal waveforms and fetal-maternal disease. This study was designed to evaluate the potential role of Doppler velocimetry as a screening test in routine prenatal care. Two hundred fifty-five pregnant women had routine monthly Doppler (systolic/end-diastolic ratio) studies on the uterine and umbilical arteries starting in the twentieth week of gestation. When a cutoff value of 3 was used at 30 weeks for the umbilical arteries, there were 35 (13%) positive tests. In 20 of these values fell to less than 3 in the ensuing weeks and were considered false positive. The remaining 15 babies demonstrated positive clinical pathologic correlates. When a value of 2.6 was used at 26 weeks for uterine arteries, there were nine positive results, seven of which had clinical pathologic correlates. This study suggested an overall positivity rate of 7%; therefore it provides encouragement for a larger venture in which screening and impact on decision making are evaluated.

Uterine and umbilical artery Doppler velocimetry in postterm pregnancy

Uterine and umbilical artery Doppler velocimetry was carried out on 149 women whose pregnancies went to 41 weeks or beyond. Flow velocity was not altered even in the presence of other signs suggestive of fetal compromise. It appears that the postdate syndrome is not associated with significant alterations in the maternal or umbilical blood flow prior to the onset of labor.

Prenatal surveillance using nonstress testing and Doppler velocimetry

One hundred forty pregnant women referred to our prenatal testing laboratory for conventional nonstress testing (NST) also had a Doppler study of the umbilical arteries. The outcomes of 88 women with abnormal testing (NST or Doppler) were compared with the outcomes of 52 women who had normal results on both tests. The results demonstrated that 50% of the fetuses with decreased flow velocity who later developed an abnormal NST were growth-retarded, 75% required a cesarean section, and 63% were admitted to the neonatal intensive care unit. Development of an abnormal NST in the presence of normal velocimetry studies occurred most frequently in the postdates pregnancy; 32% required cesarean section for fetal distress. Knowledge of the umbilical circulation through Doppler studies may be of benefit when selecting patients for NST and when interpreting results.

Pregnancy termination after detection of fetal chromosomal or metabolic abnormalities

In 3400 midtrimester amniocenteses, 68 fetuses had abnormal findings. Three women elected to continue their pregnancies and the remainder chose terminations. Of these, 29 were cared for in our hospitals. Pregnancy termination was carried out in gestations averaging 21.6 +/- 2.3 weeks and fetal weights averaging 531 +/- 351 g. Three prostaglandins techniques were used, two of which proved to be effective. Dosages employed were comparable to those used in early second trimester pregnancy terminations. Side effects were similar; one retained placenta occurred. We have used a multidisciplinary counseling approach for these couples and have restricted ourselves to the medical aspects of their problems. Techniques are described for the psychologic support of the couple during this stressful period.

Uterine artery Doppler velocimetry: the significance of divergent systolic/diastolic ratios

Continuous wave Doppler studies were carried out on both uterine arteries in 71 pregnant women from the twentieth week of gestation onward. Analysis of the waveform included the systolic/diastolic ratio and the presence or absence of a diastolic notch. In the current study, these ratios from 31 women with left/right systolic/diastolic difference, (between left and right uterine arteries) were compared with those of women having normal ratios. A normal left/right systolic/diastolic ratio difference of 0.3 with SD of 0.3 was found. When the left/right difference was plotted against the left/right averaged systolic/diastolic ratio, a correlation coefficient of 0.7 was noted (p less than 0.001). Significant outcome differences were noted between normal and abnormal left/right difference systolic/diastolic ratios in the perinatal parameters of gestational age at delivery, fetal weight, pregnancy-induced hypertension, proteinuria, and intrauterine growth retardation. Divergent uterine artery ratio findings are a result of one artery being the dominant supplier to the placenta. The majority of women with an elevated systolic/diastolic ratio seem to have divergent uterine blood supply to the uterus and placenta. These data suggest that errors in placentation site contribute to the development of preeclampsia and growth retardation in the fetus.

A classification of hypertension in pregnancy based on Doppler velocimetry

We studied 136 pregnant women with hypertension with Doppler velocimetry of the uterine and umbilical arteries. The patients were classified into four groups according to the values of the systolic/diastolic ratios. The first group had normal ratios in both the umbilical and uterine arteries. The second group had elevated umbilical ratios and normal ratios in the uterine arteries. The third group had elevated uterine artery systolic/diastolic ratios with normal umbilical artery values, and the fourth group had elevated systolic/diastolic ratios in both vessels. Women in the group with normal ratios in both the umbilical and uterine arteries were delivered of infants with a birth weight (mean +/- SD) of 3261 +/- 522 gm and gestational age of 39 +/- 2 weeks. The values for the three groups with abnormal velocimetry were: those with elevated umbilical ratios and normal ratios in the uterine arteries: body weight = 2098 +/- 811 gm, gestational age = 35.7 +/- 3.2 weeks; those with elevated uterine artery ratios with normal umbilical artery values: 2464 +/- 722 gm, gestational age = 36.3 +/- 3 weeks; and those with elevated systolic/diastolic ratios in both vessels: body weight = 1627 +/- 697 gm, gestational age = 33.3 +/- 2.7 weeks (p less than 0.01; p less than 0.001). There were 27 small for gestational age infants delivered during this study. Doppler velocimetry studies were abnormal in 26 of them (96%). Results show that Doppler-derived vascular patterns correlate well with normal and adverse perinatal outcome. A description of the uterine and umbilical systolic/diastolic ratios should be part of the clinical evaluation of all pregnant women with hypertension. This should lead to better treatment protocols and improved clinical outcome.

Uterine and umbilical artery velocimetry during normal labor

Twelve normal parturients were studied with a continuous wave Doppler unit to assess changes in uterine and umbilical velocity waveforms during labor. The analysis of these waveforms included the peak systolic/end-diastolic ratio and the evaluation of a diastolic notch. Each woman served as her own control, and all fetal heart rate tracings were normal. In latent phase labor and intact membranes, the umbilical artery systolic/end diastolic ratios before, during, and after a contraction were 2 +/- 0.2, 2 +/- 0.3 and 1.95 +/- 0.3 (N.S.). Similar results were obtained in the active phase, after rupture of membranes, or during oxytocin stimulation. This stability of the fetal cardiovascular system ensures an uninterrupted gas exchange process during the contractions (on the fetal side), enabling the great majority of term fetuses to tolerate labor with minimal if any metabolic changes. The uterine artery end-diastolic velocity fell progressively during the contraction, reaching 0 when the intrauterine pressure exceeded 35 mm Hg. Despite intrauterine pressure of greater than 60 mm Hg, the diastolic notch did not appear. Thus at term, the umbilical artery velocity waveform does not change over a wide range of uterine pressures. The changes seen in the uterine artery waveforms suggest that the end-diastolic component is primarily determined by changes in the arcuate and spiral arteries, both of which are affected during the uterine contraction.

The significance of absent end-diastolic velocity in umbilical artery velocity waveforms

Doppler umbilical artery velocimetry has been used to study high-risk pregnancies. The most extreme waveform abnormality is the absence of end-diastolic velocity. To examine the significance of this finding, events outcome was evaluated in 161 women studied between 31 and 36 weeks. Ten had absence of end-diastolic velocity. When compared with fetuses with normal and less severely abnormal waveforms, there was a higher incidence of intrauterine growth retardation, pregnancy-induced hypertension, cesarean section for fetal distress, neonatal intensive care unit admission, and low Apgar scores. Average birth weight and gestational age at delivery were lower. Five other fetuses with absence of end-diastolic velocity were identified that were delivered between 27 and 30 weeks, making a total of 15 patients with absence of end-diastolic velocity. Of 12 patients monitored, 11 had an abnormal fetal heart rate pattern. Four fetuses had lethal anomalies. There were eight perinatal deaths. Acute or chronic hypoxia was evident in all fetuses with absence of end-diastolic velocity. Absent end-diastolic velocity represents a unique and severe fetal condition that cannot be identified by present surveillance methods and requires a Doppler study for diagnosis.

The clinical significance of Doppler umbilical artery velocimetry in the small for gestational age fetus

Fifty-four women who were delivered of small for gestational age infants were studied antenatally by serially continuous-wave Doppler velocimetry. Outcomes were compared in the normal and abnormal systolic/diastolic ratio groups. Seventy-eight percent had an abnormal systolic/diastolic ratio. The group with an elevated systolic/diastolic ratio had a significantly higher incidence of abnormal fetal heart rate, pregnancy-induced hypertension, oligohydramnios, cesarean section for fetal distress, and admission into the neonatal intensive care unit. One third of the newborns required intermittent positive pressure ventilation. Average birth weight and gestational age at delivery were significantly lower and there were six perinatal deaths in the group with an elevated systolic/diastolic ratio and none in the group with a normal systolic/diastolic ratio. These data suggest that the small for gestational age fetus with normal umbilical artery velocimetry is at significantly lower risk than are those with abnormal ratios. This implies that management of the small for gestational age fetus may now be aided by a functional classification based on the umbilical artery velocity waveform.

Uterine-umbilical velocimetry in open heart surgery

The effect of the nonpulsating cardiac pump in uterine and umbilical circulation has not been studied extensively by measuring the resistance of the uterine and umbilical circulation with velocimetry. During open heart surgery, we were able to demonstrate the effects of the nonpulsatile cardiac pump.

Vaginal birth after two or more previous cesarean sections

The recommendation from the American College of Obstetricians and Gynecologists is to allow vaginal delivery after one cesarean section. This report is an update of our experience of 57 women with two or more cesarean sections who were allowed to labor.

Umbilical artery velocimetry in diabetes and pregnancy

Doppler studies of umbilical artery velocity waveforms were performed during the third trimester of pregnancy in 43 diabetic women (18 class A and 25 insulin dependent). A mean serum glucose value of 120 mg% or more was selected to indicate poor glucose control. Systolic to diastolic ratios of umbilical artery velocity waveforms were calculated to determine the degree of placental vascular resistance. A systolic to diastolic ratio of 3 or more was selected as the cut-off value for determining placental vascular disease. A significant positive correlation between systolic to diastolic ratios and serum glucose level (r = 0.52, P less than .001) was found. Elevated systolic to diastolic ratio was associated with increased number of stillbirths and neonatal morbidity. This study suggests that the risk of adverse outcome in diabetic pregnant women correlates with umbilical artery velocity waveforms.

Development of uterine artery compliance in pregnancy as detected by Doppler ultrasound

Uterine artery velocimetry was performed by means of a continuous-wave Doppler ultrasound. Serial studies were done on 12 nonpregnant and 79 normal pregnant women. Measurements were made on both uterine arteries and averaged. From the proliferative phase of the menstrual cycle through 40 weeks of pregnancy, four developmental phases are described. These changes are based on the calculation of the systolic-diastolic ratio and the disappearance of the early diastolic notch in the velocity wave. The ratio after 26 weeks averaged 2 +/- 0.3. These data provide a foundation for the study of pregnancies in which these normal evolutionary changes do not occur.

Umbilical blood flow velocity waveforms in different maternal positions and with epidural analgesia

Umbilical blood flow velocity waves were measured in the fetuses of healthy parturients in early active labor to assess the influence of different maternal positions (N = 16) and of epidural analgesia (N = 16). The ratio of systolic peak to diastolic trough (S/D) of the umbilical blood flow velocity wave is reflective of vascular resistance distal to the point of measurement on the fetal side of the placenta. Umbilical blood flow velocity wave S/D ratios were significantly higher in the supine than in either lateral position indicating that umbilical artery vascular resistance is increased when the mother lies supine. After epidural blockade, the S/D ratios were unchanged in three and lowered to varying degrees in 13 parturients indicating that this method of pain relief beneficially affects umbilical artery vascular resistance.

Uterine artery Doppler velocimetry in pregnant women with hypertension

Uterine and umbilical artery velocimetry was carried out on 71 women with hypertensive disorders in pregnancy. Three categories of hypertensive disease were diagnosed: chronic hypertension, preeclampsia, and chronic hypertension with superimposed preeclampsia. Clinical classifications describe the severity of disease effectively, primarily because the classification is based on the appearance of abnormal physical or laboratory findings. Doppler velocimetry of the uterine arteries shows that normal pregnancy occurs when the systolic/diastolic ratio is less than or equal to 2.6. When the ratio exceeds this level and there is a notch in the waveform, the pregnancy is complicated by stillbirth, premature birth, intrauterine growth retardation, and maternal preeclampsia. The positive and negative predictive value of the examination is 93% and 91%, respectively. It appears that this new technology will be an essential ingredient of optimum pregnancy surveillance.