Radiographic Diagnosis of Bile Duct Cysts

Twelve patients and a foetus with congenital bile duct cysts suggested in the majority of cases at routine upper abdominal sonography were examined by two or more of the following investigations: ultrasonorgaphy (10 patients), computed tomography (5 patients), CT-cholangiography (2 patients), oral cholecystography (7 patients), intravenous cholangiography (4 patients), endoscopic retrograde cholangiopancreatography (ERCP) (6 patients) and cholescintigraphy (2 patients). The sensitivity of each investigation for the diagnosis of bile duct cysts was: ultrasound 40 per cent, computed tomography 20 per cent, CT-cholangiography 100 per cent, oral cholecystography 17 per cent, intravenous cholangiography 75 per cent, ERCP 83 per cent and cholescintigraphy 50 per cent. When a bile duct cyst has been suggested by ultrasonography or other examinations, without a conclusive diagnosis being made, CT-cholangiography is recommended as the next examination. In patients with impaired biliary excretion of contrast medium, ERCP may be required to achieve the diagnosis.

Blood glucose level in preterm infants after antenatal exposure to glucocorticoid

AIM

To determine the impact of antenatal glucocorticoid on neonatal glucose homeostasis.

METHODS

This is a retrospective gestationally paired survey followed by a randomized study. On the basis of the interval between last antenatal dexamethasone and birth, 228 preterm infants born before 34 weeks were divided into Short (< 24 h), Intermediate (1-6 days), and Long (> or = 7 days) exposure groups and compared their gestationally paired controls. After a single course of betamethasone, the parturients remaining undelivered for one week were randomized to receive either one dose of betamethasone (n = 52) or placebo (n = 53). Glucose values were recorded at 11 time points in the first 3 days of life. Hypoglycaemic and hyperglycaemic values were counted.

RESULTS

There were no overall differences in mean glucose levels between the antenatal glucocorticoid and the control groups. However, the long exposure time to antenatal glucocorticoid was associated with increased risk of hyperglycaemia (OR 4.1; 2.2-7.6).

CONCLUSION

Antenatal glucocorticoid administration was associated with subtle disturbances of glucose homeostasis in preterm infants. These differences were dependent on the length of drug-delivery interval so that long exposition time seemed to increase the incidence of hyperglycaemia during the first days of life.

Human fetal cardiac function during the first trimester of pregnancy

OBJECTIVE

To investigate first trimester human fetal cardiac function in relation to cardiac volume blood flow, and peripheral arterial and venous blood flow patterns.

METHODS

Transvaginal Doppler ultrasonography was performed in 16 uncomplicated pregnancies at 6+, 7+, 8+, 9+, and 10+ gestational weeks. The shape of the inflow waveform and the presence of atrioventricular valve regurgitation (AVVR) were noted. The outflow mean velocity (Vmean) was calculated. The proportions of the isovolumetric relaxation (IRT%) and contraction times (ICT%) of the cardiac cycle were defined. Ductus venosus and umbilical artery pulsatility indices (PI) were obtained.

RESULTS

Every inflow waveform was monophasic before 9+ weeks. At 9+ weeks 11 of 16 and at 10+ weeks all waveforms were biphasic. At 7+ and 8+ weeks AVVR was documented in one case. At 9+ and 10+ weeks AVVR was present in four and seven fetuses, respectively. Mean (SD) outflow Vmean increased between 6+ and 8+ weeks from 3.6 (1.5) to 8.4 (3.0) cm/s (p < 0.05). IRT% decreased significantly from 6+ to 7+ weeks (39.8 (2.6) to 19.2 (6.2), p < 0.001). ICT% decreased between 8+ and 9+ weeks from 13.2 (4.0) to 8.5 (2.5) (p < 0.05). Ductus venosus PIs were unchanged. Umbilical artery Vmean increased between 7+ and 10+ weeks from 1.59 (0.51) to 5.06 (1.06) cm/s (p < 0.001) and PIs remained unchanged.

CONCLUSIONS

The first trimester of pregnancy is characterised by significant improvements in cardiac diastolic and systolic function with a concomitant increase in cardiac volume blood flow. At 10+ weeks AVVR is a common finding. Placental volume blood flow increases significantly with no change in the placental vascular impedance.

Feto-maternal distribution of ropivacaine and bupivacaine after epidural administration for cesarean section

Ropivacaine is a new amino amide local anesthetic less lipophilic and with a lower affinity for plasma proteins than bupivacaine. The purpose of this study was to examine the feto-maternal distribution of ropivacaine and bupivacaine after epidural administration for cesarean section. Healthy parturients were randomly allocated in a double-blinded manner to receive either 0.5% ropivacaine or 0.5% bupivacaine through a lumbar epidural catheter. The total and free concentrations of ropivacaine and bupivacaine were determined in the maternal and umbilical plasma. The total dose (mg/kg) required for adequate surgical anesthesia and the resulting maximum total concentrations did not differ significantly between ropivacaine and bupivacaine. The free plasma clearance of bupivacaine was higher than that of ropivacaine (7382 vs 3344 ml/min, P = 0.0001). The apparent terminal elimination half-life of ropivacaine was shorter than that of bupivacaine (6.0 vs 8.8 h, P = 0.007). At delivery, the maternal free plasma concentration of ropivacaine was more than twice that of the free concentration of bupivacaine (0.072 vs 0.032 microg/ml, P = 0.002). The free concentration of ropivacaine was about twice that of bupivacaine in the umbilical venous (0.06 vs 0.03 microg/ml, P = 0.001) and umbilical arterial (0.05 vs 0.02 microg/ml, P = 0.007) plasma. The more rapid plasma clearance of bupivacaine compared to ropivacaine, leading to lower maternal plasma concentrations and hence to lower umbilical concentrations at delivery, could be explained by the higher lipid solubility, hence greater distribution volume, of bupivacaine.

Uteroplacental Hemodynamics during Early Human Pregnancy: A Longitudinal Study

BACKGROUND

To determine normal physiologic changes in the uteroplacental hemodynamics during early placental development in the first trimester of pregnancy.

METHODS

Sixteen normal singleton pregnancies were included in this longitudinal study. Transvaginal Doppler ultrasonographic examinations of uterine, arcuate, radial and spiral arteries were performed at the 5th, 7th, 8th and 10th completed gestational weeks. Peak systolic velocity (PSV), time-averaged maximum velocity (TAMXV) and the pulsatility index (PI) were measured.

RESULTS

Uterine artery PSV, TAMXV and PI remained unchanged from the 5th to the 8th week of gestation. From the 8th to the 10th week, PSV (p = 0.02) and TAMXV (p = 0.005) increased and PI decreased (p = 0.006). Changes in the arcuate arteries were similar to those in uterine arteries. No significant changes in PSV, TAMXV or PI of the radial artery were noticed. Spiral artery PSV (p = 0.02) and TAMXV (p = 0.02) increased from the 5th to the 7th week. Thereafter they remained unchanged. Spiral artery PI decreased from the 5th to the 10th week, (p = 0.004). Throughout the study period, the PSV, TAMXV and PI values were significantly higher in the uterine artery than in the arcuate artery, and in the arcuate artery compared with the radial artery. At the 5th gestational week, no differences in PSV and TAMXV were found between radial and spiral arteries. From the 7th gestational week onwards, PSV and TAMXV were significantly lower in the radial artery than in the spiral artery. However, the PI values in the radial artery were significantly higher compared with those in the spiral artery during the whole study period.

CONCLUSIONS

Spiral artery impedance decreases and blood flow velocities increase as early as between the 5th and the 7th weeks of gestation. During that period, the uterine and arcuate artery hemodynamics remain unchanged. In the uterine and arcuate arteries, decreases in impedance and increases in absolute velocities are detected after the 8th week of gestation. This delay between the changes in the spiral and uterine arteries may represent the magnitude of the increase of placental volume and spiral arterial involvement which is needed to affect uterine hemodynamics.

Changing incidence and outcome of infants with respiratory distress syndrome in the 1990s: a population-based survey

AIM

To evaluate the trends in the incidence, clinical course and outcome of respiratory distress syndrome (RDS) in the newborn in the Oulu University Hospital region in northern Finland.

METHODS

In the population of 58 990 infants, the incidence rates of RDS specific to gestational age and birthweight in two consecutive periods, 1990-95 and 1996-99, were calculated. Clinical course and other neonatal morbidities were reported. All surviving infants were followed up until 1 y of corrected age.

RESULTS

The overall incidence of RDS did not change significantly (8.7/1000 livebirths in 1990-95 vs 7.6 in 1996-99; p = 0.15), but the gestational age-adjusted incidence decreased between the two consecutive periods (p = 0.005). The frequency of infants with gestational age below 28 wk tended to increase towards the late 1990s, while their RDS incidence remained unchanged. RDS-related neonatal mortality decreased in parallel with neonatal mortality, accounting for 15% of all neonatal deaths. The duration of oxygen therapy shortened (8.0 vs 5.5 d) and the incidence of pneumothorax decreased (9.7 vs 4.1%), whereas the rate of chronic lung disease at 36 wk of postconceptional age (16.4 vs 16.7%) and at 1 y of corrected age (9.2 vs 8.2%) remained unchanged, as did also associated neurosensory morbidity (8.8 vs 9.5%).

CONCLUSION

During the 1990s, the incidence of RDS shifted towards more immature infants and the gestational-age specific incidence decreased. The course of the disease shortened and acute complications decreased. The frequency of chronic pulmonary sequelae (and associated neurosensory morbidity) at the age of 1 y did not change significantly.

First trimester uterine, placental and yolk sac haemodynamics in pre-eclampsia and preterm labour

BACKGROUND

We hypothesized that impaired trophoblast invasion leads to umbilicoplacental blood flow disturbances that could be detected by Doppler ultrasonography during the first trimester of the pregnancy.

METHODS

After successful fresh IVF or ICSI programme, 41 of 47 enrolled subjects were followed up every 1-2 weeks between weeks 6 and 11 of gestation. Ten patients who later developed pre-eclampsia and/or preterm labour formed the study group and the control group consisted of 31 uncomplicated IVF/ICSI pregnancies. Doppler parameters of uterine, spiral, intraplacental, chorionic, umbilical and yolk sac haemodynamics were assessed.

RESULTS

At the week 8, the study group demonstrated higher (P < 0.05) maternal intraplacental resistance indices (RI) than the control group. A week later, yolk sac artery RI and umbilical artery mean velocity (V(mean)) in the study group were lower (P < 0.05) compared to the control group. In late first trimester, increased (P < 0.01) velocities and RI were observed in chorionic arteries of the study group. During early pregnancy, no difference in uterine and spiral artery haemodynamics and in umbilical artery pulsatility index (PI) values was observed between the groups.

CONCLUSIONS

Uterine and spiral artery RI and umbilical artery PI are unable to detect placental vascular disturbances during early pregnancy. Elevated intraplacental RI indicates increased maternal intraplacental impedance as early as week 8 of gestation. Decreased yolk sac artery RI and umbilical artery V(mean) in the study group at week 9 of gestation were speculated to indicate hampered transition of blood supply from yolk sac to umbilical circulation, underlining the emphasized role of yolk sac function for the maintenance of pregnancy.

Retrograde aortic isthmus net blood flow and human fetal cardiac function in placental insufficiency

OBJECTIVE

Retrograde aortic isthmus (AoI) net blood flow has been associated with diminished oxygen delivery to cerebral circulation. This study was designed to characterize the cardiac function in human fetuses with retrograde AoI net blood flow in pregnancies complicated by placental insufficiency.

METHODS

The control group comprised 43 fetuses in uncomplicated pregnancies. Study groups consisted of fetuses with placental insufficiency, and either antegrade (Group 1; n = 18) or retrograde (Group 2; n = 11) AoI net blood flow. Volume blood flows (Q) of left (LVCO) and right (RVCO) ventricles, ductus arteriosus (Q(DA)), pulmonary arterial bed (Q(P)) and foramen ovale (Q(FO)) were calculated and their proportions (%) of combined cardiac output (CCO) were determined. Ventricular ejection forces were calculated. Blood velocity waveforms of the mitral (MV) and tricuspid (TV) valves were obtained. The proportion of left ventricular isovolumetric relaxation time (IRT%) of the cardiac cycle, and index of myocardial performance (IMP) were calculated.

RESULTS

In Group 1, Q(DA)% was increased (P < 0.05) and Q(P)% decreased (P < 0.05) compared with the control group, and Q(FO)% was greater (P < 0.01) compared with the control group and Group 2. In Group 2, the distribution of CCO did not differ from that of the control group. Ventricular ejection forces were similar among the groups. In Group 2, the MV early filling/atrial contraction time-velocity integral ratio was greater (P < 0.05) compared with those of the control group and Group 1. In Groups 1 and 2, IRT% and IMP were increased (P < 0.001) compared with the control group.

CONCLUSIONS

In placental insufficiency, fetuses with antegrade AoI net blood flow show a shift in RVCO from the pulmonary to the systemic circulation, and Q(FO) makes up the majority of LVCO. Fetuses with retrograde AoI net blood flow fail to demonstrate these changes, suggesting a relative drop in the oxygen content of the blood entering the left ventricle.

Ultrasonographic Features following Thermal Balloon Endometrial Ablation Therapy

The aim of this study was to evaluate the ultrasonographic changes taking place in the uterus after thermal balloon endometrial ablation therapy. The ultrasonographic findings in the uterus after thermal balloon endometrial ablation in 13 patients were compared to those found in 13 patients treated with gestagen therapy. Examinations took place before initiation of the treatment, on the 1st postoperative day (thermal balloon ablation group only), and 1 and 6 months later. One month after thermal balloon endometrial ablation therapy, the ultrasonographic examination revealed a clear-limited hyperechogenic zone surrounding the uterine cavity which was filled with fluid in 6 out of 10 patients. The ultrasonographic findings may represent a burn-injury-induced obstruction in the cervical canal with subsequent collection of fluid in the uterine cavity and a zone of coagulation in the submucosal layers. At the final examination in the thermal balloon group, the mean endometrial thickness was lower than the pretreatment level. No changes were observed in the gestagen therapy group.

Retrograde net blood flow in the aortic isthmus in relation to human fetal arterial and venous circulations

OBJECTIVES

To characterize changes in the human fetal arterial and venous circulations associated with retrograde aortic isthmus net blood flow.

METHODS

Study groups consisted of fetuses with placental insufficiency and/or fetal growth restriction and either antegrade (Group 1; n = 18) or retrograde (Group 2; n = 11) net blood flow in the aortic isthmus. The control group comprised 31 fetuses in uncomplicated pregnancies. Pulsatility indices of the umbilical, middle cerebral and proximal pulmonary arteries and the descending aorta, and pulsatility indices for veins of the ductus venosus and inferior vena cava were calculated. Right and left ventricular fractional shortenings were ascertained. The coronary artery blood flow was visualized and the presence of tricuspid regurgitation was noted.

RESULTS

In the study groups, the umbilical artery and descending aorta pulsatility indices were significantly higher (P < 0.05), and those of the middle cerebral artery lower (P < 0.001), than in the control group, with no difference between the two study groups. The proximal pulmonary artery pulsatility index was significantly higher in Group 2 (P < 0.001) than in Group 1 and the control group. In Group 2, the right ventricular fractional shortening was significantly lower (P < 0.01) than in Group 1. Coronary artery blood flow was visualized significantly more often (P < 0.03) and tricuspid regurgitation was present more frequently (P < 0.003) in Group 2 than in Group 1. In Group 2, the ductus venosus pulsatility index for veins was significantly higher than in Group 1 (P < 0.01) and the control group (P < 0.01), with no difference in the inferior vena cava pulsatility index for veins.

CONCLUSIONS

Fetuses with retrograde aortic isthmus net blood flow demonstrate a rise in right ventricular afterload and increased pulsatility in ductus venosus blood velocity waveforms.

Transplacental passage of oxcarbazepine and its metabolites in vivo

PURPOSE

The purpose of this study was to investigate human fetal exposure to oxcarbazepine (OCBZ) in vivo.

METHODS

Transplacental passage and placental tissue concentrations of OCBZ and its metabolites were determined. Maternal venous blood, cord blood, and placental tissue samples from 12 mothers using OCBZ during pregnancy alone or in combination with other antiepileptic drugs were collected. Samples were analyzed with high-performance liquid chromatography.

RESULTS

Maternal venous concentrations of OCBZ and its major metabolites were at same range as cord blood concentrations (OCBZ in maternal serum, 0.19 +/- 0.16 microg/ml, and in cord serum, 0.21 +/- 0.19 microg/ml; 10-hydroxy-10,11-dihydrocarbamazepine (10-OH-CBZ) in maternal serum, 5.69 +/- 2.49 microg/ml, and in cord serum, 5.23 +/- 1.44 microg/ml; 10,11-trans-dihydroxy-10,11-dihydrocarbamazepine (10,11-D) in maternal serum, 0.29 +/- 0.22 microg/ml, and in cord serum, 0.28 +/- 0.14 microg/ml). OCBZ (0.17 +/- 0.16 microg/g placental tissue), 10-OH-CBZ (3.49 +/- 1.34 microg/g placental tissue) and 10,11-D (0.25 +/- 0.11 microg/g placental tissue) were detected in the placental tissue. The amount of OCBZ detected from placental tissue was 0.01% of the daily dose.

CONCLUSIONS

OCBZ, like other antiepileptic drugs, is transferred significantly through the placenta in humans.

Effects of bleeding on uteroplacental, umbilicoplacental and yolk-sac hemodynamics in early pregnancy

OBJECTIVE

To determine the influence of vaginal bleeding with or without a persisting subchorionic hematoma on uteroplacental, umbilicoplacental and yolk-sac hemodynamics in early pregnancy.

DESIGN

Twenty-six consecutive patients with vaginal bleeding entered this longitudinal study 1-3 days after the beginning of vaginal bleeding and were re-examined every 1-2 weeks. In three cases vaginal bleeding occurred at the 5th completed gestational week, in 13 at the 7th week, in nine at the 8th week and in one case at the 10th week. A subchorionic hematoma was identified in one case at the 5th week, in nine cases at the 7th week, in nine cases at the 8th week, and in seven cases at the 10th week. Four pregnancies ended in miscarriage. Blood velocity waveforms of uterine, arcuate, radial, spiral, umbilical, chorionic and yolk-sac arteries were obtained by transvaginal pulsed Doppler ultrasound and peak systolic velocities, time-averaged maximum velocities and pulsatility indices were calculated. The results were compared with our earlier observations in normal pregnancy obtained with a similar study protocol.

RESULTS

At the 7th week, radial artery pulsatility-index values (mean (SD)) were higher in pregnancies with vaginal bleeding (1.84 (0.59); P = 0.04) and in pregnancies with a subchorionic hematoma (1.96 (0.63); P = 0.03) than in normal pregnancies (1.40 (0.46)). The pulsatility-index values of uterine, arcuate, spiral, umbilical and chorionic arteries did not differ between the groups. Vaginal bleeding with or without a subchorionic hematoma at the 8th week did not affect any of the measured parameters. Persistence of the subchorionic hematoma until the 10th week did not affect uterine, arcuate, radial, spiral, umbilical or chorionic artery hemodynamics. Yolk-sac hemodynamic parameters did not differ between the groups.

CONCLUSIONS

Vaginal bleeding with or without a subchorionic hematoma is associated with increased radial artery impedance at the 7th week of pregnancy. Persistence of the subchorionic hematoma does not affect utero- and umbilicoplacental circulation.

Combination of cervical interleukin-6 and -8, phosphorylated insulin-like growth factor-binding protein-1 and transvaginal cervical ultrasonography in assessment of the risk of preterm birth

OBJECTIVE

To determine the value of combinations of cervical interleukin-6 (IL-6), cervical interleukin-8 (IL-8), the phosphorylated isoform of insulin-like growth-factor binding protein-1 (IGFBP-1), and cervical ultrasonography in the prediction of preterm birth.

DESIGN

Prospective follow up.

SETTING

Oulu University Hospital maternity clinic from February 1997 to July 1998.

POPULATION

Women with singleton pregnancies (n = 77), referred from outpatient clinics at 22-32 weeks of gestation with symptoms (uterine contractions) or signs (cervical change) of threatened preterm birth. Symptomless women (n = 78) matched for gestational age, parity and maternal age at recruitment were studied as a reference group.

METHODS

A urine sample for bacterial culture was collected, and cervical swab samples for assays of interleukin-6 and -8 and phoshorylated IGFBP-1 were taken before digital cervical examination. A Pap smear for analysis of bacterial vaginosis and samples for analysis of chlamydia and streptococci were also obtained. Cervical measurements were made by transvaginal ultrasonography. The same sampling and cervical measurement were repeated twice at two-week intervals. The cutoff values of the markers were determined by receiver-operating characteristic curve analysis.

MAIN OUTCOME MEASURE

Preterm birth (<37 weeks).

RESULTS

The preterm birth (<37 weeks) rate for women in the study group was 16% (12/77). The cervical interleukin-6 cutoff value (61 ng/L) at first visit had a sensitivity of 73% and a specificity of 61% in predicting preterm birth, with a positive likelihood ratio (LR+ ) of 1.9 (95% CI 1.2-3.0). An ultrasonographically measured cervical index value of > 0.36 at recruitment predicted preterm birth in 25% (5/20) of the study group compared with 9% (5/54); LR+ 2.2 (95% CI 1.03-4.7). Cervical phosphorylated IGFBP-1 > 6.4 microg/L [LR+ 1.8 (95% CI 0.7-2.9)], interleukin-8 > 3739 ng/L [LR+ 1.4 (95% CI 0.9-2.4)], and ultrasonograpic cervical length < 29.3 mm [LR+ 2.7 (95% CI 0.8-9.7)] increased the risk of preterm birth. According to the logistic regression model, a combination of IL-6, and IL-8 and cervical index increased the specificity to 97%, but the sensitivity fell to 30% in detecting preterm birth. There was a significantly increased incidence of puerperal infections if phosphorylated IGFBP-1 concentrations were elevated (> 21.0 microg/L), 36% (4/11) compared with 4.6% (3/65), LR+ 6.7 (95% CI 2.7-17), the sensitivity being 67% (4/6) and the specificity 90% (63/70). Elevated phosphorylated IGFBP-1 concentrations (> 21.6 microg/L) were also associated with an increased risk of neonatal infections; LR+ 8.0 (95% CI 3.5-18).

CONCLUSIONS

An increase in cervical IL-6 concentration and the ultrasonographically measured cervical index appear to be associated with preterm birth. A combination of these markers with measurement of cervical IL-8 appears to be the best predictor of preterm birth. Neither the sensitivity nor specificity of the tests used in this study are good enough to predict preterm birth for clinical decision making. Cervical phosphorylated IGFBP-1 seems to be a marker of puerperal and neonatal infectious morbidity in cases of threatened preterm delivery, suggesting early tissue degradation at the choriodecidual interface.

Umbilical artery N-terminal peptide of proatrial natriuretic peptide in hypertensive pregnancies and fetal acidemia during labor

OBJECTIVE

To assess the activity of the human fetal atrial natriuretic peptide system in hypertensive pregnancies with and without signs of increased fetal systemic venous pressure and in pregnancies complicated by fetal acidemia during labor.

METHODS

Umbilical artery plasma N-terminal peptide of proatrial natriuretic peptide concentrations were measured in neonates by radioimmunoassay. The control group consisted of 50 neonates with uncomplicated gestation and labor. In group 1, there were 22 newborns of hypertensive pregnancies. Doppler ultrasonography showed abnormal umbilical artery blood velocity waveform in five cases and normal nonpulsatile umbilical vein blood velocity profile in every case. Group 2 consisted of five newborns of pregnancies complicated by maternal hypertensive disorder. Atrial pulsations in the umbilical vein and retrograde diastolic blood velocity pattern in the umbilical artery were detected in every case. Group 3 was composed of 27 newborns of uncomplicated pregnancies with fetal acidemia (pH 7.10 or less) during labor.

RESULTS

In groups 1-3, N-terminal peptide of proatrial natriuretic peptide concentrations were higher (P <.001) than in the control group. In group 1, neonates with abnormal umbilical artery blood velocity pattern had higher N-terminal peptide of proatrial natriuretic peptide concentrations than neonates with normal umbilical artery Doppler findings (P <.006). N-terminal peptide of proatrial natriuretic peptide concentrations were higher in group 2 (P <.002) than in groups 1 and 3. CONCLUSIONS Maternal hypertensive disorder and fetal acidemia during labor stimulate fetal atrial natriuretic peptide production, which was greatest in fetuses with severe placental insufficiency and signs of congestive heart failure.

Thermal balloon endometrial ablation therapy induces a rise in uterine blood flow impedance: a randomized prospective color Doppler study

OBJECTIVE

To evaluate the possible hemodynamic changes in uterine blood flow using transvaginal color Doppler ultrasonography after thermal balloon endometrial ablation therapy.

STUDY DESIGN

Prospective randomized study.

PATIENTS AND METHODS

Twenty-seven pre- and post-menopausal women with either menorrhagia or endometrial hyperplasia (no sign of atypia) were randomized to receive either thermal balloon ablation therapy (n = 13) or gestagen therapy (n = 14). In the gestagen therapy group, a 3-month period of medroxy-progesterone acetate (10 mg/day) was given to premenopausal women during cycle days 15-24 and it was given to postmenopausal women continuously. Thermal balloon endometrial ablation therapy was carried out on cycle days 3-8. All the color Doppler measurements were also carried out on cycle days 3-8. Flow waveforms were obtained from the main branch of the uterine arteries, from arcuate arteries and from a subendometrial spiral artery. Doppler flow parameters were used for subsequent statistical analysis. The measurements took place before the initiation of treatment, on the first postoperative day (thermal ablation group only), and 1 month and 6 months after initiation of the study.

RESULTS

No within-group or between-group differences were detected until the time of the last measurement 6 months after initiation of the treatment. Between the two randomized groups, the pulsatility index (PI) was significantly higher in the thermal ablation group in all three arteries in comparison with the gestagen group, in which no change in the PI took place. In the thermal ablation group, a significant rise from the pretreatment level was observed in the PI in the uterine arteries and in the spiral artery 6 months after the therapy.

CONCLUSION

Thermal balloon endometrial ablation therapy induces a rise in uterine blood flow impedance, but not until 6 months after the treatment. The rise in impedance may be due to fibrosis in the uterine cavity which thermal balloon therapy has been shown to produce.

A randomised controlled trial of vaginal clindamycin for early pregnancy bacterial vaginosis

OBJECTIVE

To determine whether treatment of bacterial vaginosis (BV) with vaginal clindamycin affects pregnancy outcome.

MATERIALS AND METHODS

Mothers with singleton pregnancies and without previous preterm delivery in 17 health centres in Oulu from March 1996 Until March 1998, in whom BV was diagnosed by Gram stain of a vaginal swab at the first antenatal visit (at the 12th gestational week) were randomised at Oulu University Hospital to have a one-week course of vaginal clindamycin, or placebo. A follow up sample of Gram stain was taken two weeks after randomisation and at the 30th gestational weeks. Pregnancy outcome data was obtained from hospital records. Primary outcome was preterm birth, and puerperal infectious morbidity the other outcome measure.

RESULTS

During the study period 1956 women were screened, of whom 143 (7.3%) were BV- positive. One hundred and one were randomised. The total preterm birth rate of BV+ women randomised was 9.9% (10/101). Preterm birth occurred in 20.7% (6/29) vs 0% (0/26) according to whether BV persisted or not (P < 0.01). The preterm birth rate was 13.7% (7/51) in the clindamycin group vs 6.0% (3/50) in the placebo group (OR 2.5, 95% CI 0.6-10). BV was cured just after treatment in 17 out of 51 (33%) of the clindamycin- treated patients vs 17 out of 50 (34%) of the placebo- treated patients (OR 1.0, 95% CI 0.4-2.2). There was a difference in puerperal infectious morbidity in patients where BV persisted (31%, 9/29) compared with those in which BV did not persist (7.7%, 1/26) (OR 5.4, 95% CI 1.04-28). Infections were seen in 4/51 (8%) of the clindamycin treated vs 10/50 (20%) of the placebo treated cases, (OR 0.3, 95% CI 0.1-1.2).

CONCLUSION

The prevalence of BV was lower than expected in this low risk population, but nevertheless it increased the risk of preterm birth and puerperal infectious morbidity, the risk being highest in cases where BV persisted during pregnancy. Vaginal clindamycin treatment for BV in the first trimester of pregnancy did not appear to reduce the risk of preterm birth or puerperal infections.

Fetal adrenal artery velocimetry measurements in appropriate-for-gestational age and intrauterine growth-restricted fetuses

OBJECTIVE

To investigate adrenal artery blood flow in the fetus.

DESIGN AND METHOD

Sixty-two appropriate-for-gestational-age (AGA) and 20 intrauterine growth-restricted (IUGR) fetuses were recruited to this cross-sectional study between 22 and 42 weeks of pregnancy in a tertiary referral fetal medicine unit of a university hospital.

ENDPOINTS

Doppler velocimetry of the fetal adrenal, umbilical (UA), renal and middle cerebral arteries (MCA). Pulsatility index (PI), resistance index (RI), peak systolic velocity (PSV), time-averaged maximum velocity (TAMXV) and cerebroplacental ratio (MCA RI/UA RI; CPR). Obstetric outcome.

RESULTS

The adrenal artery was detected in 82% of the fetuses. All flow velocity waveforms obtained from the adrenal artery indicated low impedance blood flow. No significant changes in PI, RI, PSV and TAMXV occurred with advancing gestation. The blood flow parameters of the adrenal artery did not differ between AGA and IUGR fetuses. In five IUGR fetuses with signs of redistribution of cardiac output in favor of the brain, the adrenal artery velocimetry results were unremarkable. The adrenal artery PI, RI, PSV and TAMXV values were higher in female fetuses than in male fetuses (P < 0.05). A relationship was observed between the velocity measurements and the estimated fetal weight (P < 0.01).

CONCLUSIONS

The fetal adrenal artery could be readily detected. We observed no redistribution of blood flow in favor of the fetal adrenals in IUGR fetuses which were not severely compromised.

Association of severe placental insufficiency and systemic venous pressure rise in the fetus with increased neonatal cardiac troponin T levels

OBJECTIVE

The aim of this study was to test the hypothesis that severe placental insufficiency and a rise in fetal systemic venous pressure are associated with fetal myocardial cell damage, which in turn leads to increased neonatal troponin T levels.

STUDY DESIGN

Sixty-six neonates born after uncomplicated pregnancy and delivery were included in the control group. Study groups 1 and 2 consisted of 32 and 5 neonates, respectively, born to women with hypertensive disorder. In study group 1 the fetal intra-abdominal portion of the umbilical vein showed normal nonpulsatile blood flow pattern in every case. In study group 2 all the fetuses had atrial pulsations in the intraabdominal umbilical vein. After delivery blood samples were collected from the umbilical arteries, and cardiac troponin T concentrations were measured with commercially available enzyme-linked immunosorbent assay kits. A clinically significant troponin T level was set at >/=0.10 ng/mL.

RESULTS

In study group 1 the maternal main uterine arterial blood flow pattern was normal in 30 cases and abnormal in 2 cases. Umbilical artery blood velocity waveforms were normal in 26 fetuses, 4 fetuses had a decreased diastolic blood flow, 1 fetus had an absent diastolic blood flow pattern, and 1 fetus had a retrograde diastolic blood flow pattern. In study group 2 maternal uterine arterial Doppler findings were abnormal in every case, and all the fetuses had retrograde diastolic blood flow pattern in the umbilical artery. Neonatal troponin T levels were <0.10 ng/mL in the control group (0-0.14 ng/mL) and in study group 1 (0-0.16 ng/mL), except for 1 case in each group. Every neonate in study group 2 had a troponin T level >0.10 ng/mL, with the range from 0.11 to 0.35 ng/mL. In study group 2 troponin T concentrations were significantly higher (P <.0001) than in either the control group or study group 1.

CONCLUSION

Neonatal troponin T levels are not clinically significantly increased in normal pregnancies and in pregnancies complicated by maternal hypertensive disorder but with normal fetal umbilical venous return. Neonatal troponin T concentrations are significantly increased in the presence of abnormal umbilical venous return, which indicates myocardial cell damage.

Preterm delivery for maternal or fetal indications: maternal morbidity, neonatal outcome and late sequelae in infants

OBJECTIVE

To assess maternal morbidity, and neonatal outcome and especially long term sequelae in infants born preterm due to maternal or fetal indications.

DESIGN

Analysis of retrospective cohort.

SETTING

Oulu University Central Hospital, Finland.

POPULATION

One hundred and three women, who were between the 24th and the 33rd week of pregnancy, delivered by caesarean delivery because of maternal or fetal indications. They were matched with 103 women who had spontaneous preterm delivery at corresponding gestational weeks between 1990-1997.

MAIN OUTCOME MEASURES

Maternal morbidity, reasons for caesarean delivery, neonatal mortality and morbidity rates, and later development of the infants.

RESULTS

Pre-eclampsia was diagnosed in 57% of the women in the indicated group and only in one woman in the control group. All infants in the indicated group and almost a third in the control group were born by caesarean birth; the main indication was threatening fetal asphyxia. There was a significant difference in neonatal mortality rates between the groups (175 vs 78 per thousand live births in the indicated vs control infants; RR 2.3, 95% CI 1.02, 4.9) and the main cause of death was respiratory insufficiency: 64% in the indicated group and 22% in the controls; RR 2.9, 95% CI 0.8, 10. Respiratory distress syndrome occurred more often (73% vs 53%, RR 1.4, 95% CI 1.1, 1.7) and it was more severe and more complicated in infants in the indicated group, compared with those in the control group. Symptomatic chronic lung disease at one year of age was more common in infants in the indicated group than in the control group (15% vs 3%; RR 4.6, 95% CI 1.4, 15.9).

CONCLUSIONS

Not only the risks of neonatal mortality and morbidity but also long term pulmonary consequences, appear to be greater in infants born preterm by indicated delivery than in preterm infants born spontaneously at corresponding weeks.

Transvaginal salpingosonography for assessing tubal patency in women previously treated for pelvic inflammatory disease and benign ovarian tumors

OBJECTIVE

The aim of this study was to evaluate the role of transvaginal salpingosonography in the assessment of tubal patency among women previously treated conservatively for pelvic inflammatory disease and surgically for a benign ovarian tumor.

DESIGN

Twenty-two women were recruited for this study at the University Hospital of Oulu. Transvaginal salpingosonography was scheduled to be performed twice within a 3-month interval. X-ray hysterosalpingography was chosen as a reference method and was performed within 2 days of the second salpingosonography examination during the same menstrual cycle. Altogether, 31 Fallopian tubes were assessed with the second salpingosonography examination and X-ray hysterosalpingography.

RESULTS

Twenty-nine Fallopian tubes were observed by both methods to be patent (i.e. 29 tubes by each method, but not necessarily the same tubes). An occlusion was diagnosed by each method in two tubes only, of which one appeared occluded by both methods, while one tube from each method appearing to be occluded was demonstrated to be patent using the other method. The agreement of transvaginal salpingosonography compared with X-ray hysterosalpingography was 94%, the sensitivity 50%, the specificity 97%, the positive predictive value 50% and the negative predictive value 97%. Two successive transvaginal salpingosonography examinations were performed in 18 patients with 27 Fallopian tubes. Disagreement was observed for only one tube. The agreement between these two examinations was 96%, the sensitivity 100%, the specificity 96%, the positive predictive value 67% and the negative predictive value 100%. The kappa coefficient was 0.78 (95% confidence interval 0.75-0.81).

CONCLUSIONS

In conclusion, transvaginal salpingosonography can be used in patients with previous pelvic inflammatory disease and adnexal surgery due to its ease of use, reliability and low costs on an out-patient basis. Among these patients, tubal patency was a common finding.

Yolk sac and umbilicoplacental hemodynamics during early human embryonic development

OBJECTIVES

To determine the relationship between the yolk sac and umbilicoplacental circulations during the first trimester of pregnancy.

DESIGN

Sixteen normal singleton pregnancies were included in this longitudinal study. Transvaginal ultrasonography with color and pulsed Doppler was performed at 5+, 7+, 8+ and 10+ gestational weeks. Fetal heart rate and blood velocity waveforms of yolk sac, umbilical and chorionic arteries were obtained.

RESULTS

The detection rate of arterial blood flow in the yolk sac increased significantly from 5+ (2/16) to 7+ gestational weeks (12/16). Thereafter, it declined significantly and no arterial blood flow was detected at 10+ weeks. When the arterial blood flow was observable in the yolk sac, all waveforms consisted of continuous diastolic blood flow. There were no significant changes in peak systolic velocity (PSV), time-averaged maximum velocity (TAMXV), pulsatility index (PI) or resistance index (RI) values of the yolk sac arteries during the study period. In umbilical arteries, blood flow was detected in two of 16 patients at 5+ weeks and in all cases thereafter. The mean umbilical artery PSV (SD) increased from 7.2 cm/s (3.7) at 8+ weeks to 13.0 cm/s (2.9) at 10+ weeks (p = 0.001). No changes in PI values were found and the absence of diastolic flow was typical of the umbilical artery during the study period. In chorionic arteries, blood flow was detected in six out of 16 subjects at the 5+ week, in 14 out of 16 patients at the 7+ week and in every case thereafter. No changes in PSV or TAMXV values were found.

CONCLUSIONS

Our results showed that the arterial signals in the yolk sac circulation disappeared and the umbilicoplacental circulation increased between 8+ and 10+ weeks of gestation. This indicates that the placenta replaces the yolk sac as an essential source of blood supply to the embryo at that time.

The effect of a levonorgestrel-releasing intrauterine system on uterine artery blood flow, hormone concentrations and ovarian cyst formation in fertile women

To determine the effect of long-acting intrauterine progestin on the impedance to blood flow in the uterine arteries, we applied a levonorgestrel-releasing (20 microg/day) intrauterine contraceptive system (LNG-IUS) to the uterine cavity of 27 fertile, regularly menstruating women. Measurements were performed using transvaginal colour Doppler ultrasonography in the mid-luteal phase and on day 1 of menstruation in the absence of the LNG-IUS and 3 months later in its presence. The mean (SD) mid-luteal uterine artery pulsatility index (PI) had risen from a pretreatment level of 2.28 (0.48) to 2.70 (0.67) after 3 months use of the LNG-IUS (P < 0.01), but as regards day 1 of menstruation, no change was observed. The increase in the mean PI (SD) at the mid-luteal phase was present only in subjects with serum levonorgestrel concentrations >200 pg/ml (n = 16) [pretreatment, 2.25 (0.47); with LNG-IUS, 2.83 (0.59), P < 0.001], and absent in those with serum levonorgestrel concentrations <200 pg/ml (n = 10) [pretreatment, 2.31 (0.53); with LNG-IUS, 2.51 (0.79), ns]. Mean progesterone concentrations were lower with the LNG-IUS in place in both groups. We conclude that a levonorgestrel-releasing intrauterine device appears to increase the impedance to blood flow in the uterine arteries during the mid-luteal phase in correlation with serum concentrations of LNG and a concomitant decrease in serum progesterone concentrations.

Assessing tubal patency with transvaginal salpingosonography after the reversal of tubal ligation for female sterilization

The objective of this study was to assess tubal patency using transvaginal salpingosonography (TSSG) among women treated by tubal ligation after sterilization and to compare these results with those obtained using X-ray hysterosalpingography (HSG). Twenty-one healthy women were recruited. Air was used as a contrast medium in TSSG and Omnipaque as a water-soluble contrast medium in the HSG examination. All women underwent at least one TSSG. If the woman did not become pregnant during the follow-up or had a miscarriage or tubal pregnancy, she was re-examined with a second TSSG and the results were compared with those of HSG undertaken during the same menstrual cycle. Because of the high pregnancy rate the final number of patients was reduced to 10. The observed agreement between the two TSSGs was 70%, which was low compared with our earlier results. The kappa coefficient was only 0.41. The sensitivity of TSSG for the detection of tubal occlusion was 54%. This can be explained by the fact that the mean time interval between the two TSSGs was long (5.5 months) and results were not therefore comparable or repeatable. We can conclude that the women with patent tubes became pregnant after the first TSSG while the women taking part in the second TSSG had impaired tubal function. There were more occluded tubes observed in the second TSSG than in the first. An analysis comparing the second TSSG with HSG produced better results. The observed agreement was 84%, kappa coefficient 0.67, demonstrating a good reproducibility of TSSG; the sensitivity of TSSG for the detection of tubal occlusion was 83%, specificity 85%, positive predictive value 91% and negative predictive value 75%. Thus, TSSG should be regarded as a reliable, rapid, safe and inexpensive method for testing tubal patency after reversal of tubal ligation for sterilization. It also allows simultaneous scanning of the uterine corpus, endometrium and ovaries and may have a clearing action on occluded tubes. TSSG can thus replace X-ray HSG in the primary evaluation of tubal status, even in this special group of patients.

Perinatal and neonatal outcome and late pulmonary sequelae in infants born after preterm premature rupture of membranes

OBJECTIVE

To evaluate fetal outcome and long-term impact of very early preterm premature rupture of membranes (PROM).

METHODS

In a retrospective cohort study, 78 women with singleton pregnancies who delivered at the Oulu University Central Hospital between 1990 and 1996 and who had early PROM, between the 17th and 30th gestational weeks, were matched with 78 women with spontaneous preterm delivery during the same time (control group). The main outcome measures were maternal morbidity, interval from early PROM to delivery, perinatal and neonatal mortality rates and neonatal morbidity, need for primary and recurrent hospitalization and later pulmonary complications of the infants, and growth and neurologic findings at 1 year of corrected age.

RESULTS

The perinatal mortality was 282 per 1000 births in the early PROM group and 256 per 1000 births in the control group. Histopathologically defined chorioamnionitis and puerperal infections were significantly more common in the early PROM group than in controls (51 versus 29%, odds ratio [OR] 2.5, 95% confidence interval [CI] 1.3, 4.9 and 38 versus 22%, OR 2.3, 95% CI 1.1, 5.1, respectively). There were no differences in neonatal infections between groups. Pulmonary hypoplasia was detected more often in the early PROM group (in nine infants) compared with the control group (no infants). The duration of rehospitalization up to 1 year of age due to respiratory problems was a mean of 5 days in the early PROM group and a mean of 1 day in the control group (P = .01; 95% CI 0.9, 6.9). Symptomatic chronic lung disease at 1 year of age was detected more often in the early PROM group than in controls (22 versus 9%; OR 2.4, 95% CI 0.9, 6.5).

CONCLUSION

Early PROM seems to be a major obstetric and neonatal problem with pulmonary ramifications extending beyond the neonatal period. However, most of these infants can be saved.

The effect of diclofenac on uterine artery blood flow resistance during menstruation in patients with and without a copper intrauterine device

The aim was to evaluate the effect of diclofenac on uterine artery blood flow resistance during the first day of menstruation. A total of 28 regularly menstruating women were examined longitudinally with and without a copper intrauterine contraceptive device (IUD) by transvaginal colour Doppler ultrasonography. The uterine artery pulsatility index (PI) was first measured, after which 50 mg of diclofenac was infused i.v. After 15 min the PI was measured again. The patients evaluated their menstrual pain with a scoring system before and after the diclofenac infusion. The mean PI (SD) during menstruation was significantly lower with the IUD [2.13 (0.43)] than without [2.39 (0.62)], P = 0.05. The mean PI in nine patients who experienced advanced menstrual pain was also lower in the presence of the IUD [2.16 (0.42)] than without it [2.83 (0.78); P < 0.05]. Diclofenac was effective in revealing menstrual pain both with and without the IUD, and reduced the PI in the absence of an IUD [pre-treatment 2.39 (0.62) versus post-treatment 2.12 (0.45); P < 0.001], but had no effect when the IUD was present [pre-treatment 2.13 (0.43) versus post-treatment 2.10 (0.41)]. The results indicate that by inhibiting prostaglandin synthesis one can reduce the resistance to blood flow in the uterine arteries during menstruation. This does not hold true when an IUD is present, however, suggesting that the device might induce the production of vasoactive agents other than prostaglandins in the surrounding tissue.

The effects of a copper-intrauterine device on the uterine artery blood flow in regularly menstruating women

The aim of the study was to evaluate the effect of a copper-intrauterine device (IUD) on uterine artery blood flow during the midluteal phase and on the first day of the menstrual cycle using pulsed colour Doppler ultrasonography. Twenty-one regularly menstruating women (18-45 years) who were willing to use copper-IUD contraception participated in the study. The patients were first examined without the IUD in the midluteal phase 6-9 days before the expected onset of menstruation and on the first day of menstruation, after which the IUD was inserted. Three months later the patients were examined again on the corresponding cycle days. The patients estimated the level of dysmenorrhoeic pain with a scoring system. Transvaginal ultrasonography with colour flow imaging was used to measure the pulsatility index (PI) in the uterine arteries. There were no significant changes in the uterine artery blood flow after the insertion of the IUD during menstruation or in the midluteal phase. In patients with increased IUD-related pain during menstruation (n = 5), however, there was a decrease in PI (2.87 +/- 0.52 versus 2.41 +/- 0.23, P = 0.05) after IUD insertion. The decrease in the mean PI was present in all five patients. In conclusion, copper-IUD does not induce any major changes in the resistance of the uterine artery blood flow, although during menstruation in patients with increased menstrual pain after IUD insertion there seems to be a decrease in the uterine artery PI.

A randomized study comparing air to Echovist as a contrast medium in the assessment of tubal patency in infertile women using transvaginal salpingosonography

This study was undertaken to compare two different contrast media (air and Echovist) in the assessment of tubal patency using transvaginal salpingosonography (TSSG) in 32 infertile women referred to an infertility outpatient clinic. Altogether, 59 Fallopian tubes were examined with TSSG. Laparoscopic chromopertubation was used as a reference method. In group A (air), concordance was 90%, Cohen's kappa coefficient 0.71 [95% confidence interval (CI): 0.64-0.77], sensitivity 63%, specificity 100%, negative predictive value 88% and positive predictive value 100%. In group B (Echovist), the corresponding parameters were as follows: 93%, 0.71 (CI: 0.67-0.76), 60, 100, 93 and 100% respectively. No statistically significant differences were found between these two contrast media. Either one can reliably be used for assessing tubal patency with TSSG in infertile women as a primary phase examination modality.

Effect of the levonorgestrel-releasing intrauterine system on the uterine artery pulsatility index in postmenopausal hormone replacement therapy

The aim of this study was to determine the effect of continuous intrauterine release of progestin on the uterine artery pulsatility index (PI) in women on postmenopausal hormone replacement therapy (HRT). The voluntary participants, 13 symptomatic postmenopausal women received transdermal estradiol (50 micrograms/day) for 1 month before combining the levonorgestrel-releasing (20 micrograms/day) intrauterine system (LNG-IUS) with estrogen replacement therapy. The PI of uterine artery blood flow was measured by transvaginal color Doppler ultrasonography before the onset of HRT, 1 month after the treatment with estradiol (estradiol-only phase) and 1, 3 and 6 months after insertion of the LNG-IUS. The mean uterine artery PI decreased significantly from its pretreatment level after 1 month of transdermal estradiol treatment (p < 0.05), but the LNG-IUS induced an increase in PI, and 6 months after its insertion the PI did not differ significantly from the pretreatment level (p > 0.05). Compared with the estradiol-only phase, the last measurement of the PI was significantly increased (p < 0.05). The results suggest that continuous intrauterine release of levonorgestrel abolishes the vasodilatory effect on the uterine arteries accomplished by postmenopausal estradiol treatment.

Reproducibility of transvaginal Doppler velocimetry measurements in the uterine arteries of postmenopausal women

Intraobserver and interobserver reproducibility of transvaginal Doppler velocimetry measurements in uterine arteries were assessed by two observers in 20 postmenopausal women. In addition, the agreement between the observers regarding the detection of an ovary as well as the presence or absence of intraovarian arterial blood flow was documented. Pulsatility index (PI), peak systolic velocity (PSV) and time-averaged maximum velocity (TAMV) measurements in uterine arteries were made twice by the same investigator (IJ). Thereafter, the same measurements were made by the second investigator (AT). The agreement in categorical data was studied by using 2 x 2 tables and Cohen's kappa-coefficient. Reproducibility of the Doppler measurements was analyzed by using coefficient of variation, repeatability coefficient, intraclass correlation coefficient, mean differences and limits of agreement. In addition, the 95% confidence interval was calculated as appropriate. There was agreement of 95-100% between the observers with respect to the detection of an ovary in transvaginal scanning. Agreement regarding the presence or absence of intraovarian arterial blood flow, however, was only 75-81%. Intraobserver repeatability was very good, the intraclass correlation coefficient being 0.98-0.99 and the coefficient of variation 6% in PI measurements. The PSV measurements showed an intraclass correlation coefficient of 0.94-0.96 and a coefficient of variation of 10-12%. The intraclass correlation coefficient for TAMV measurements was 0.94 and the coefficient of variation varied from 12 to 16%. Interobserver agreement was good. There was no bias between the observers' measurements. The intraclass correlation coefficient for PI measurements was between 0.93 and 0.95, and the coefficient of variation was 11%. For PSV measurements, the intraclass correlation coefficient was 0.79-0.80 and the coefficient of variation was 18-29%. TAMV measurements showed an intraclass correlation coefficient of 0.83-0.84 and a coefficient of variation of 19-29%. When the limits of agreement for Doppler velocimetry measurements are considered, we expect the two observers to give PI measurements that differ by less than 0.7, with any discrepancy being equally likely in either direction. In conclusion, based on the high intraclass correlation coefficients, the intraobserver repeatability of all Doppler parameters was very good, the most reliable measurement being the PI. Variation in PSV and TAMV measurements increased considerably, however, when Doppler velocimetry was carried out by two investigators instead of one.

Agreement between two successive transvaginal salpingosonography assessments of tubal patency

OBJECTIVE

To evaluate the agreement between repeat transvaginal sonographic assessments of tubal patency using a combination of air and saline.

MATERIAL AND METHODS

Twenty-nine patients were examined twice by the same investigator (H.S.). There was a three-month interval between the observations, and the investigator was blinded to the results of the first examination. Each patient was evaluated using three categories classified as: 1) bilateral patency, 2) unilateral patency and 3) bilateral occlusion. In addition, the pooled data from individual tubes was examined with respect to the detection of patency or occlusion. Data from the right and left tubes were analyzed separately as well. Agreement between the two examinations was subsequently determined using Cohen's kappa coefficient (kappa). When there were more than two categories, a weighted kappa coefficient was used.

RESULTS

There was good (kappa = 0.61) agreement between the two examinations when each patient was evaluated individually. For the pooled data of all tubes (n = 46), the kappa coefficient was 0.53, but increased to 0.66 after correction for prevalence. There was no systematic bias between the successive examinations of tubes. There was more consistency between repeated observations in the right (kappa = 0.70) than in the left (kappa = 0.37) tubes. The prevalence of occlusion was higher in the left tubes.

CONCLUSION

Transvaginal salpingosonography was shown to be a reliable method for the assessment of tubal patency.

The clinical significance of an absent end-diastolic velocity in the umbilical artery detected before the 34th week of pregnancy

BACKGROUND

The aim of this study was to evaluate the clinical significance of absent or reversed (ARED) flow detected in the late second or early third trimester in the umbilical artery in high-risk pregnancies.

METHODS

Eighty-three women with hypertensive disorders of pregnancy, gestational diabetes or a suspected disorder of the fetus (e.g. small-for-gestational age) were included in this retrospective study. A constant finding of ARED flow in the umbilical artery was registered with the pulsed Doppler method between the 23+/-0 and 33+/-6 gestational weeks. Perinatal mortality (PNM) rates, Apgar scores and arterial umbilical pH values, birth weights, the frequency of SGA, gestational ages at birth, NICU (=neonatal intensive care unit) days, anomalic fetuses and the mode of delivery were registered. Mann-Whitney U-test and chi-squared test were used for statistical analysis.

RESULTS

The PNM in the entire group under study was 19.3% (16 infants/fetuses). The rate of structurally or chromosomally abnormal fetuses was 15.7% (13 infants/fetuses). When anomalic fetuses were excluded the PNM was 18.6%. No non-anomalic fetuses/newborns were lost in cases in which ARED was detected after the 30th week. No statistically significant difference was observed in PNM and SGA frequencies when comparing AEDV (absent end-diastolic velocity) fetuses with those who had REDV (reversed end-diastolic velocity). When anomalic fetuses were excluded the PNM rate in the AEDV group was 8.9% compared with the PNM rate of 35.7% in the REDV group; (p=0.03).

CONCLUSIONS

An early ARED finding (before the 34th week) in the umbilical artery signifies a marked warning signal of fetal distress. In these cases the rates of perinatal morbidity and mortality are very high, which is a reflection of the severity of the condition. The majority of fetuses can, however, be saved.

Intraobserver variation in transvaginal Doppler blood flow measurements in benign ovarian tumors

Intraobserver variation in transvaginal color Doppler ultrasound measurements in ovarian tumors was evaluated in 20 women selected from a group of patients undergoing surgical exploration for an ovarian lesion. Only those cases who were suspected of having a benign ovarian tumor other than a unilocular simple cyst were recruited. Pulsatility index (PI), resistance index (RI), peak systolic velocity (PSV) and time-averaged maximum velocity (TAMXV) were measured from intratumoral arteries in two repeat ultrasound sessions by the same observer. In each session, only two vessels with optimum Doppler signals were investigated. The repeatability of the measurements was studied by calculation of the within-subjects standard deviation (SD), the value below which the difference between the repeat measurements will lie with a probability of 0.95, the coefficient of variation (CV) and the intraclass correlation coefficient (intra-CC). The CV was 15% for the PI, 13% for the RI, 17% for the PSV and 23% for the TAMXV when the average value from two vessels was used. The corresponding intra-CC values were 0.86, 0.83, 0.96 and 0.90, respectively. In contrast, when a lowest (PI or RI) or a highest (PSV or TAMXV) value was preferred, the CV increased to 25% for the PI, to 18% for the RI, to 28% for the PSV and to 33% for the TAMXV. Similarly, the intra-CC values decreased. All in all, the averaged PI and RI measurements in intratumoral arteries were considered to be reliable. Averaged PSV and TAMXV measurements had high CV figures, raising some doubt as to the consistency of these variables. Averaged index values were more consistent than the extreme (lowest or highest) values.

Assessment of tubal patency with transvaginal salpingosonography after treatment for tubal pregnancy

Tubal patency was studied in 32 patients who had previously undergone a laparoscopic or laparotomy procedure (salpingostomy, salpingectomy or tubal resection), or who had received a local injection of hypertonic glucose because of tubal pregnancy. Transvaginal salpingosonography (TSSG) was subsequently performed in the follicular phase of the menstrual cycle, and laparoscopic chromopertubation was carried out as a comparative method after TSSG. Of 32 patients (47 Fallopian tubes examined), the affected tube was observed to be patent by TSSG in 68%. The contralateral tube was patent in 93%. Nine patients became pregnant and were thus not subsequently assessed with laparoscopy. Two of these pregnancies ended in a miscarriage and one in a recurrent tubal pregnancy. A concordance of 86% for Fallopian tubes was achieved between the TSSG and laparoscopic chromopertubation methods. When checking the Fallopian tubes separately, the concordance for the results in the affected tubes was 67%, and 100% for the contralateral tube. Therefore TSSG appears to be a practical method for the primary examination of tubal patency in patients treated previously for tubal pregnancy. Guidelines for the treatment of infertility after tubal pregnancy can also be set out according to TSSG findings.

Single bolus compared with a fractionated dose injection technique of bupivacaine for extradural Caesarean section: effect on uteroplacental and fetal haemodynamic state

We studied 26 healthy parturients undergoing elective Caesarean section, allocated randomly to receive extradural block with 0.5% plain bupivacaine in a double-blind manner in either a single bolus or fractionated doses. After a 3-ml test dose, an additional 20 ml of bupivacaine were given over a 5-min period in the single bolus group (n = 13) and over a 25-min period in the fractionated dose group (n = 13). We studied the effects of bupivacaine on blood flow velocities in the maternal placental and non-placental uterine and fetal umbilical arteries before and four times during establishment of extradural block using a pulsed colour Doppler technique. Median sensory block reached T3 in the single-dose group compared with T4 in the fractionated-dose group. Two subjects in each group required i.v. ephedrine to correct transient hypotension (systolic arterial pressure < 90 mm Hg). Blood flow velocity waveform indices of the uterine and umbilical arteries did not differ significantly within or between groups during the study. There was no significant difference in neonatal outcome, as assessed by Apgar scores and umbilical artery pH values. In conclusion, we observed no deterioration in uteroplacental circulation after administration of a single bolus dose of bupivacaine.

Long-term outcome of fetal hydrocephaly

Long-term outcome of 25 fetuses with ventriculomegaly diagnosed before delivery who survived the neonatal period up to school age was examined at 10.1 (standard deviation, 2.6) years of age. Twelve children had normal motor and mental development, seven were severely handicapped, and six showed intermediate outcome. The fetuses with severe handicaps on long-term follow-up had more severe ventricular dilation than the fetuses with good long-term outcomes. Eighteen of the children had surgical treatment, and seven of them had normal long-term development. Thirty percent of surviving fetuses with ventriculomegaly have poor long-term outcomes. In isolated progressive ventriculomegaly, early delivery as soon as fetal lung maturity allows might be reasonable for achievement of better long-term prognosis.

Maternal and uteroplacental haemodynamic state in pre-eclamptic patients during spinal anaesthesia for Caesarean section

We have studied the effects of crystalloid (Ringer's acetate 1 litre) preloading and subsequent spinal anaesthesia in 12 pre-eclamptic parturient patients undergoing elective Caesarean section. Maternal placental uterine artery circulation was measured using a pulsed colour Doppler technique with simultaneous measurement of maternal haemodynamic state. Despite preloading, mean maternal systolic arterial pressure (SAP) decreased significantly and marked maternal hypotension (SAP < 80% of baseline value) was recorded in two patients after induction of spinal anaesthesia. Mean central venous pressure increased significantly after preload, but decreased to baseline shortly after induction of spinal anaesthesia. Mean pulsatility index (PI) in the uterine artery did not change during preload or spinal block. In one patient, uterine artery PI increased significantly when SAP decreased to 71% of the baseline value, 14 min after induction of spinal anaesthesia. These results suggest that preload with crystalloid solution does not prevent maternal hypotension in pre-eclamptic patients, and that changes in uterine artery velocity waveforms were minor when SAP was 80% or more of baseline during spinal anaesthesia. These changes did not appear to have any major effect on the clinical condition of the neonate, as assessed by Apgar score and umbilical artery pH values.

Controversies in assessment of ovarian tumors with transvaginal color Doppler ultrasound

BACKGROUND

The observations made in the late 1980s indicated that the transvaginal color Doppler ultrasound can be used in the detection of ovarian cancer. This has generated a stream of clinical trials. The conflicting results of numerous publications, however, have led to a major controversy. The aim of this communication is to review the literature and our own observations in order to provide more insight into the subject.

RESULTS

The performance characteristics of the 32 previous transvaginal color Doppler ultrasound studies showed a considerable heterogeneity: the sensitivity was 25%-100%, the specificity was 46%-100%, the positive predictive value was 28.6%-100% and the negative predictive value was 63%-100%. The accuracy varied between 57% and 100%. An indisputable overlap was found between the ranges of pulsatility index (PI) and resistance index (RI) values from the benign and malignant adnexal tumors. The RI was <0.40 in 43% of benign tumors and in 25% of the normal vascular ovaries.

CONCLUSION

The current cut-off levels for PI or RI values should not be used in clinical decision making due to their poor specificity.

The intensity of labor pain in grand multiparas

BACKGROUND

The purpose of the current study was to investigate differences in pain experiences and requirements for pain control in parturients with different birth experience. Previous studies have shown that the labor pain experience is significantly less intense in multiparas than in primiparas and requirements for analgesic treatment have therefore been assumed to be minimal in this group.

METHODS

The pain experience during labor was assessed by 70 consecutive grand multiparas (a minimum of five previous deliveries) compared to that of primiparous (n=70) and II-V parous women (n=70). Pain intensity was repeatedly assessed on a pain intensity scale (0-10) according to the progress of cervical dilatation at the first and second stage of labor.

RESULTS

During the latent phase of cervical dilatation (0-3 cm) grand multiparas had a median pain score of 3 compared to 4 in II-V paras and 6 in primiparas (p<0.001). At the end of the first stage and during the second stage the intensity of pain in grand multiparas was significantly higher compared to that in primiparas (median scores 7 to 8 vs 6 to 7, p<0.05). Epidural blocks were administered to 40% of primiparas, 3% of II-V paras and to no grand multiparas (p<0.0001). Twenty-one percent of grand multiparas rated their pain as intolerable (pain scores 9-10) during the second stage compared to 10% of primiparas (p<0.05%). On the third day after delivery, 47% of grand multiparas regarded their analgesia insufficient.

CONCLUSIONS

The majority of parturients, including grand multiparas, suffered from intense pain during labor. After delivery, a significant number of grand multiparas felt that they had received insufficient pain relief.

Comparison of uterine blood flow characteristics between spontaneous and stimulated cycles before embryo transfer

The Doppler blood flow characteristics of uterine arteries were evaluated prospectively in 57 patients undergoing embryo transfer. A total of 32 women underwent frozen-thawed (FT) embryo transfer during a spontaneous menstrual cycle (FT-embryo transfer), and 25 patients underwent in-vitro fertilization treatment (IVF-embryo transfer). The endometrial thickness, pulsatility index (PI), maximum peak systolic velocity (MPSV), minimum diastolic velocity (MDV) and flow velocity waveform type of the uterine artery blood flow were assessed with transvaginal colour Doppler ultrasonography before embryo transfer. The mean (SD) endometrial thickness was 9.2 (2.0) mm in FT-embryo transfer patients and 12 (3.4) mm in IVF-embryo transfer patients (P < 0.0003). There were no conception cycles in which the uterine arteries bilaterally had a flow velocity waveform with an absent end-diastolic flow. Compared to spontaneous cycles, the median PI was statistically lower and the MDV was higher in IVF cycles. In contrast, no difference was found in the median MPSV values between the two groups. There was no difference in Doppler velocimetry measurements between the conception and non-conception cycles in either the FT-embryo transfer or the IVF-embryo transfer groups. In conclusion, an inadequate uterine blood flow impaired implantation, while optimum uterine blood perfusion did not necessarily lead to conception.

Intraobserver reproducibility of transvaginal Doppler measurements in uterine and intraovarian arteries in regularly menstruating women

The intraobserver reproducibility of the pulsatility index (PI), resistance index (RI) and maximum peak systolic velocity (MPSV) measurements in uterine and intraovarian arteries was assessed in ten regularly menstruating women by means of transvaginal pulsed Doppler ultrasound. Three different sources of variation in repeat measurements, i.e. beat-to-beat, between-frame and temporal variability, were studied using the coefficient of variation (CV) and intra-class correlation coefficients. Beat-to-beat and between-frame variabilities in all Doppler parameters were negligible. The following figures were obtained from the assessment of temporal variability. The uterine artery PI and MPSV measurements had a CV of 10% and 15%, respectively. Intra-class correlation coefficients for these parameters were 0.99 and 0.88, respectively. In the intraovarian arteries, the CV was between 15 and 19% for the PI and between 8 and 12% for the RI. The CV values for intraovarian MPSV measurements were 14 and 16%. In contrast, the intra-class correlation coefficients for the intraovarian MPSV measurements showed considerable variation, from 0.63 to 0.68. Uterine artery Doppler velocimetry proved to be a reliable method. The PI and RI measurements in the intraovarian arteries were also reproducible. In contrast, the inconsistency observed in velocity measurements in the intraovarian arteries raises some doubt as to the reliability of these measurements.

Postpartum haemorrhage

Most cases of postpartum haemorrhage are caused by uterine atony, maternal soft-tissue trauma, retained placenta or its parts, and obstetric coagulopathy. The factors most significantly associated with haemorrhage include advanced maternal age, prolonged labour, pre-eclampsia, obesity of mother, multiple pregnancy, a birth weight of more than 4000g, and previous postpartum haemorrhage. It seems that multiparity itself is only a weakly associated factor. The prophylactic use of oxytocic drugs (oxytocin or its combination with ergometrine at the third stage of labour is always recommended for decreasing the bleeding. Prostaglandins should be used as a second line treatment if uterine atony cannot be abolished by uterine massage and oxytocin infusion. In the surgical management, the role of hypogastric artery ligation is decreasing. The stepwise uterine devascularization may be a reasonable method in the most severe uncontrollable postpartum bleeding. The uterine tamponade with gauze or specific tubes may also be a useful alternative in some cases. Selective arterial embolization is a promising new method that seems to have success in controlling the heavy postpartum bleeding unresponsive to more usual measures. However, the value of this method should be evaluated in bigger series.