Early amniocentesis and congenital foot deformities

OBJECTIVE

Several studies have shown an increased risk of congenital foot derformities after early amniocentesis. These studies have comprised amniocenteses performed before 13 completed gestational weeks. In this study, the risk of foot deformities after amniocentesis performed at 12-14 completed gestational weeks was determined.

METHODS

3,469 genetic amniocenteses in singleton pregnancies performed before 15 completed gestational weeks were studied. The intention was to perform the amniocenteses at 12-14 weeks of gestation, but 32 amniocenteses were performed at the gestational age 11 weeks + 5 days or 11 weeks + 6 days. The pregnancies were followed up with regard to fetal loss and leakage of amniotic fluid. After birth, newborns with a diagnosis of foot deformity were identified from the Swedish Medical Birth Registry. The observed number of foot deformities was then compared with the expected number which was calculated stratified for delivery hospital, year of birth, and maternal age.

RESULTS

The observed number of foot deformities was significantly higher than the expected: exact odds ratio 1.74 (exact 95% confidence interval 1.06-2.69). The rate of spontaneous abortions after the procedure was 1.8%, and the rate of leakage of amniotic fluid was 1.9%. There was a significant trend for all complications to decrease with increasing gestational age at amniocentesis.

CONCLUSION

Women undergoing amniocentesis at 11+5 to 14+6 gestational weeks have an increased risk of giving birth to a child with a congenital foot deformity.

[Folic acid protects against neural tube defects. But how many women of reproductive age have been informed about this fact?]

The involvement of folic acid in the aetiology of neural tube defects (NTDs) has been discussed for decades. Both observational and controlled intervention trials have shown periconceptional folic acid supplementation (PFAS) to significantly reduce the incidence both of first-time and recurrent NTDs. PFAS may also be associated with reduction in the incidence of certain other congenital malformations, preterm delivery, and intra-uterine growth retardation. However, the mechanism whereby folic acid exerts its protective effect remains unclear. Thermolabile 5,10-methyl-enetetrahydrofolate reductase was the first folate-related enzyme to be associated with an increased risk of NTDs. This genetic variant may result in increased plasma homocysteine levels, which have been linked to an increased risk of NTDs. The folate-dependent genetic variants known today can explain no more than 30-50 per cent of the observed protective effect of folate. However, available evidence suggests low maternal folate status itself to be the major determinant of NTD risk. Since the vast majority of NTDs are first occurrences, and in Sweden a large proportion of fetuses with spina bifida remain undetected at routine ultrasonography during pregnancy, primary prevention by means of PFAS represents a major potential public health asset, capable of reducing both mortality and morbidity due to NTDs. Accordingly, implementation of a national strategy to reduce the incidence of NTDs, and promote awareness among health care providers and women of reproductive age of the benefits of PFAS is strongly to be recommended. Although supplemental folic acid tablets are the best proven means of improving folate status, compliance may be a problem, which emphasises the importance of considering a nutrient fortification programme as a complementary strategy for reducing the incidence of NTDs.

Genetic analysis of the cytochrome P450 CYP2D6 polymorphism in patients with systemic lupus erythematosus

Previous reports of an association between the polymorphic cytochrome P450 CYP2D6 and systemic lupus erythematosus are conflicting. Following the elucidation of the molecular basis of the CYP2D6 genetic polymorphism, we re-examined the hypothesis of an association of this gene with a susceptibility to system lupus erythematosus by analysing the complete CYP2D6 coding sequence. For this purpose, we studies the occurrence of 16 mutations in genomic DNA from 69 systemic lupus erythematosus patients and a large control group using a previously described polymerase chain reaction-single strand confirmation polymorphism analysis. In addition, we studied the occurrence of 11 alleles and 21 genotypes in the same individuals by the combined use of restriction fragment length polymorphism and allele-specific polymerase chain reaction followed by polymerase chain reaction-single strand confirmation polymorphism analysis. No significant differences in the distribution of overall genotypes and predicted phenotypes were observed between system lupus erythematosus patients and controls. The only new finding of our study is the higher frequency of one non functional allele, namely the CYP2D6*4A, in systemic lupus erythematosus versus control individuals (P = 0.007). This increased frequency was not statistically significant in multiple comparison analysis and was not related to any specific clinical features of systemic lupus erythematosus. These results suggest that CYP2D6 genotype as well as CYP2D6 phenotype are not determinant of susceptibility to systemic lupus erythematosus but the presence of the inactive CYP2D6*4A allele may be a contributory factor.

Amniocentesis before the 15th gestational week in single and twin gestations-complications and quality of genetic analysis

BACKGROUND

Early amniocentesis has been claimed to confer a higher risk of fetal loss than standard amniocentesis after the 15th gestational week. Our experience of early amniocentesis in single and twin gestations from 1990 - 1995 is presented with 99.3% follow-up.

METHODS

Amniocentesis was performed between 11 gestational weeks + 5 days and 14 gestational weeks + 6 days.

RESULTS

In 1646 pregnancies 1678 amniocenteses were performed. Thirty-two reamniocenteses were done, 17 due to amniocyte culture failure and 15 due to failure to obtain sufficient amount of amniotic fluid on the first occasion. After puncture 1.49% (25/1678) suffered a spontaneous abortion. Twenty twin pregnancies were included. One spontaneous abortion was noted in this group, as well as three cases where one fetus was normal and the other had a severe defect. Selective abortions were performed without complications.

CONCLUSIONS

The difference of postprocedure fetal loss in our population between early and standard amniocentesis is 0.8%. A comparison of postprocedure losses is not appropriate when amniocenteses are performed at a different gestational age, as spontaneous loss decreases with increased gestational age. Our results compare well with the only randomized study between early and standard amniocentesis where the fetal loss after early amniocentesis is similar to that in standard amniocentesis.

Factors influencing informed choice of prenatal diagnosis: women's feelings and attitudes

OBJECTIVE

To obtain knowledge about factors that could influence women's informed choice and extent of prenatal diagnosis, her feelings when implementing it, and her satisfaction.

METHOD

A questionnaire including Visual Analogue Scale was given to 823 women and replies received from 662 (80.4%). Ease of choice was the basis for the statistical analysis.

RESULTS

The factors that most often influenced choice were the fetus health, maternal age, and knowledge of the consequences. The choice was easy to make, only 2% finding it very difficult. The time period from the amniocentesis until the results were available was the most difficult time reported.

CONCLUSIONS

The choice of method for prenatal diagnosis was very easy for most women. Satisfaction with choice was high (98%). Extra support can be needed while awaiting results of invasive prenatal diagnosis.

Parental reactions to fetal echocardiography

The impact of fetal echocardiography (FE) was studied in 65 families where a previous child had been born with heart disease and where FE showed normal cardiac anatomy in the fetus. Forty-six of the families had lost their child with heart disease (Group 1), while the child was alive in 19 of the families (Group 2). A questionnaire concerning the attitude of the parents toward FE was sent to all families. The possibility of having FE had influenced the decision to have another child in 64% in Group 1 and in 26% in Group 2 (P < 0.01). If a serious cardiac malformation had been found at FE, 69% in Group 1 and 29% in Group 2 would have chosen abortion (P < 0.01). The anxiety decreased significantly in both groups after FE. Of the participating mothers, 96% wishes FE at the next pregnancy. The study indicates that FE probably is very important to families who had previously had a child with a serious malformation but also that many families intend to continue the pregnancy even if a malformation is diagnosed.

Women's informed choice of prenatal diagnosis: early ultrasound examination-routine ultrasound examination-age-independent amniocentesis

The antenatal clinics in the catchment area of the Department of Obstetrics and Gynecology, University Hospital, Lund, were divided into a study group and a control group. At the study antenatal clinics during a 15-month period 1,004 pregnant women received a written and verbal information that a routine ultrasound examination during gestational week 18 should be considered as a prenatal diagnostic method. They even got information on alternatives: to decline all, to have an early abdominal ultrasound examination, or to have both a routine ultrasound examination and an amniocentesis performed. At the control antenatal clinics, 1,408 pregnant women received standard information. No women in either group chose not to have an ultrasound examination performed, but 1% chose an early abdominal examination in the study group. The percentage of women older than 35 years who asked for an amniocentesis was equal in the two groups. However, women younger than 35 years in the study group requested amniocentesis significantly more frequently than the women in the control group.

Fluid characteristics of benign ovarian cysts: correlation with recurrence after puncture

OBJECTIVE

To determine whether concentrations of gonadal steroids and fibrinolytic indices in fluid from benign ovarian cysts can discriminate between functional and neoplastic cysts and predict recurrence after ultrasound-guided puncture.

METHODS

Concentrations of gonadal steroids and components of the plasminogen-activating system were measured in cyst fluid obtained at ultrasound-guided puncture of 96 ovarian cysts and were related to subsequent cyst recurrence. In 83 patients who had surgery for benign ovarian cysts, components of the plasminogen-activating system in the cyst fluid were correlated with the histopathologic diagnosis.

RESULTS

Higher levels of plasminogen activators and lower levels of inhibitors were found in those 54 cysts that recurred after puncture and in cysts with low levels (below 2000 pmol/L) of estradiol (E2). This enzyme-inhibitor balance resulted in high fibrinolytic activity. In contrast, cysts with high E2 levels (above 2000 pmol/L) had lower levels of activators, higher levels of inhibitors, and virtually no fibrinolytic activity. A high E2 concentration in cyst fluid was the single best predictor of no recurrence after puncture. Sixteen of 18 cysts in postmenopausal women recurred, and all had low levels of E2. However, an index based on cyst fluid volume and concentrations of E2 and urokinase predicted recurrence even better. A high concentration of urokinase in the fluid correlated with neoplastic histology of the cysts obtained at laparotomy.

CONCLUSION

The fluid content of ovarian steroids and plasminogen activators and inhibitors is related to histopathology and recurrence after puncture of benign ovarian cysts. Puncture and assay of these components may minimize surgery on functional cysts.

Four cases of absent ductus venosus: three in combination with severe hydrops fetalis

Ductus venosus links the umbilical vein and the portal vein to the inferior vena cava. It is of great significance for the developing fetus but of minor importance to the growing infant where it normally obliterates and is transformed to the ligamentum venosum. An absent ductus venosus implies that the oxygenated blood from the umbilical vein has to circulate through the liver. We report 4 cases with this malformation. Prenatally, three fetuses had an extreme hydrops, especially hydrothorax. In two fetuses hydrops was severe already in the second trimester of pregnancy. Termination was performed. In the third case, hydrops was first diagnosed in the 36th week of gestation. The fourth case had an ultrasound examination in the 34th week of gestation. There was no hydrops but a disproportion with a very small head and abdominal diameter compared to femur length. Postpartum both these infants died. At autopsy, the only structural malformation in the three hydrops cases was an absent ductus venosus. In the fourth case there were other anomalies.

Insidious urinary retention after vaginal delivery: prevalence and symptoms at follow-up in a population-based study

The purpose of this study was to investigate the prevalence of postpartum urinary retention in women after vaginal delivery and to determine whether parturients with retention develop voiding problems later. During a 3-month period, all parturients in the catchment area of the University Hospital, Lund, were investigated 3 days after delivery, residual volume being measured by ultrasonography. All those with postpartal retention were contacted 4 years after delivery, when they were reexamined by ultrasonography and asked to fill in a questionnaire regarding urinary problems. In all, 539 women were scanned post partum, and 8 (1.5%) had a residual volume exceeding 150 ml (range 156-320 ml). Retention was more common among primiparae after instrumental delivery or epidural analgesia. The symptoms were normalized spontaneously within a few days in all cases. At follow-up 4 years later, the prevalence of urinary symptoms was not higher than that in the general population. Ultrasonography to detect urinary retention does not seem to have any place in the normal postpartal care. However, extended supervision may be appropriate in parturients receiving epidural analgesia or in those submitted to instrumental deliveries.

Pneumothorax in pregnancy

Since 1957, only 15 cases of isolated spontaneous pneumothorax in pregnancy have to our knowledge been reported in the English literature. The treatment of pneumothorax in pregnancy is more difficult than in non-pregnant patients. A case is reported and therapy discussed.

Cystic lesions in elderly women, diagnosed by ultrasound

A retrospective review of an entire clinical series of 152 women over 50 years of age, in whom cystic lesions without solid parts had been diagnosed by ultrasound, found there were no malignancies in 58 completely anechoic lesions less than 5 cm in diameter. Of 10 small lesions (less than 5 cm in diameter) with some echogenicity or septa, one was a borderline tumour. In contrast, in patients with lesions greater than 5 cm in diameter there were three malignancies in the group of 33 totally anechoic cysts, five in the group of 32 cysts with some echogenicity, and as many as eight malignancies in the 18 lesions where several septa were present. Two borderline and one malignant tumour had been missed at previous clinical examination. We conclude that small anechoic lesions are seldom, if ever, malignant in elderly women. Sonography is helpful in patients with a negative clinical examination when pelvic pain or signs of malignancy are present.

Ultrasound measurement of the ovarian volume

The ovaries of 377 women between the age of 40 and 70 years were measured by ultrasound. About one third of the patients were postmenopausal. Mean value, standard deviation and S.E.M. of the ovarian volume were calculated and related to age, parity and menstrual cycle. Ovarian size decreased with age in all women but bore no relation to parity and day of menstrual cycle in the menstruating group of women over 40 years of age. A diagram of the ovarian volume related to age is presented. In postmenopausal women the volume was related to estrogen treatment, age, parity and years since menopause. In the group of women receiving orally administered estrogens for at least a year the p-values for all parameters were greater than 0.005. Furthermore, the ovarian volume of women under hormonal treatment did not decrease with age. On the other hand the most important factor for ovarian size in subjects not receiving estrogen treatment was age (p = 0.0056). The results presented here will serve as a prerequisite for sonar examination of the ovaries in women at high risk for development of ovarian carcinoma.

Hemostasis following inoculation and during spreading of colon carcinoma in the rat

Platelet function following inoculation of chemically induced carcinoma was evaluated in the rat. The original line of tumor (NGW1) was obtained using N-methyl-N-nitrosoguanidine. After trypsin homogenation a cell suspension of 0.3 X 10(6) viable tumor cells was injected subserosally in the cecum of each animal. Controls received injections of equal volumes of 0.9% NaCl solution or trypsin. The animals were subjected to laparotomy 2, 4, and 6 weeks after inoculation. Platelet function was assessed in vivo by measuring bleeding time and blood loss during mesenteric vessel transection or liver resection upon laparotomy. Hemoglobin, hematocrit, platelet count, activated partial thromboplastin time, platelet aggregation, thromboxane B2, platelet factor 4, and fibrinogen levels were evaluated after sacrifice by exsanguination. Significant decrease in bleeding time and blood loss was observed in animals with local primary tumors as well as in rats with lymph node metastases. Hemoglobin and hematocrit were decreased in the presence of metastases. Platelet count was not changed. Activated partial thromboplastin time was not affected by the presence of tumor. Platelet aggregation in vitro was accelerated in the presence of primary tumor or lymph node metastases, as well as following addition of tumor cells to platelet suspensions. No changes in thromboxane B2 or platelet factor 4 could be registered. Fibrinogen levels were decreased in the presence of liver metastases. Enhancement of primary hemostasis and platelet function in the presence of colon carcinoma in the rat was demonstrated both in vivo and in vitro. Direct or indirect interaction of the tumor cell with thrombocytes may play a role in determining the metastatic potential of the neoplasm.

Nephrosis and disturbances of neuronal migration in male siblings--a new hereditary disorder?

Two male siblings (a boy aged 2 years 10 months at death and a male fetus aborted in gestational week 22) showed similar brain and kidney malformations, comprising paraventricular heterotopias, central canal abnormalities (including hydrocephalus in the boy), and glomerular kidney disease with proteinuria. There were no known hereditary diseases in the families of the parents, and there was one healthy sibling of either sex. The malformations thus seem to be hereditary in an autosomal or possibly X linked recessive fashion.

The diagnosis and course of antenatal urinary tract dilatation

During 1980-1984 the ultrasound examination (US) performed in the third trimester revealed urinary tract dilatation in 18 foetuses. After delivery all the infants were reexamined within the first weeks with US, intravenous pyelography and micturition urethrocystography to confirm the malformation. Pelvic dilatation was seen in 12 foetuses, 5 bilaterally. The dilatation was caused by pelviureteric obstruction in 6 infants, 4 of which were operated on with dismembered pyeloplasty. In 6 infants the dilatation was caused by distal ureteric stenoses, and 5 of them were operated on. Two foetuses with dilated pelvis and ureter had distal ureteric stenosis and both were operated. Four infants with the diagnosis of unilateral multicystic kidney, confirmed postnatally, were nephrectomised. At the follow-up the kidney function was normal in 15 infants and slightly decreased in 3 infants with bilateral malformations. The antenatal US revealed pelvic dilatation, but the diagnosis of a dilated ureter was inaccurate. Prenatal urinary tract dilatation should be controlled via US shortly after delivery and, if persistent, evaluated further by means of x-ray examinations.

Placental grading with ultrasound in hypertensive and normotensive pregnancies. A prospective, consecutive study

Placental grading was studied prospectively with real-time ultrasound in 654 consecutive pregnancies. The placental maturation was clearly demonstrated in both unselected and hypertensive pregnancies. No differences in placental grading were found between normotensive and hypertensive pregnancies. Fetal outcome was not associated with different placental grades and a grade III placenta was not predictive of an adverse outcome. The value of antenatal placental grading in unselective and hypertensive pregnancies could not be demonstrated.

Asymptomatic bacteriuria during pregnancy with special reference to group B streptococci

The relationship between significant bacteriuria (SB), i.e. 2 subsequent voided urine specimens with greater than or equal to 10(5) colony forming units (CFU)/ml, and the occurrence of bacteria in the urinary bladder detected by bladder punction, was investigated in asymptomatic pregnant women. From 30 (70%) of the 43 women with SB studied, bacteria were isolated from the urinary bladder. The same bacteria were found in the bladders of all 21 women with Escherichia coli, the one with Klebsiella pneumoniae, and the one with Staphylococcus saprophyticus in midstream urine. Six of 10 patients with group B streptococci (GBS), 1 of 4 patients with Streptococcus faecalis, and none of 5 patients with Staphylococcus epidermidis in voided specimens had bacteria in the aspirated urine. Serotype III was isolated from 8/10 patients with SB caused by GBS. One child born to a woman with GBS SB but no bacteria in the urinary bladder, got early onset septicaemia. The poor predictive value of SB with GBS, S. faecalis and S. epidermidis necessitates the increased use of bladder puncture for diagnosis of true asymptomatic bacteriuria (AB), i.e. AB with bacteria in the urinary bladder. SB with GBS even without bacteria in the urinary bladder, may constitute a threat to the baby's health.

Amniocentesis in treatment of acute polyhydramniosis in twin pregnancies

A rare complication in twin pregnancy is acute polyhydramniosis. If left untreated, the perinatal mortality is 100%. The clinical courses of two cases treated with ultrasound-guided amniocentesis are presented. In the first case altogether 4875 ml amniotic fluid was drained. Both twins died within the first 24 hours of life after delivery in gestational week 26. In the second case 2150 ml amniotic fluid was drained. Both twins survived and were delivered in good condition in gestational week 35. We recommend ultrasound-guided amniocentesis to be performed in twin pregnancy affected by acute polyhydramniosis.

The advantage of antenatal diagnosis of intestinal and urinary tract malformations

In a 24-month prospective screening programme 6020 pregnant women were examined with diagnostic ultrasound at 17 and 32 weeks gestation. In a total of 23 (0.38%) abnormalities, four cases of urinary tract and two of intestinal tract abnormalities were discovered. The antenatal diagnosis influenced the management of these disorders both before and after birth.

Prenatal diagnosis of fetal brain ventricle dilatation

In a 13 month prospective screening programme 3120 pregnant women were examined with diagnostic ultrasound at 17 and 32 weeks gestation; five fetuses (0.16%) were found with dilatation of brain ventricles. Early diagnosis was made in one patient resulting in legal termination of the pregnancy. The four other patients were diagnosed at the second ultrasound examination.

Diagnostic ultrasound in threatened abortion and suspected ectopic pregnancy

200 women threatened with abortion during the first 16 weeks of pregnancy were examined with diagnostic ultrasound to determine whether there were signs of intrauterine life. Of the 90 who showed positive signs, 8 aborted spontaneously later, the other 82 continued their pregnancy. The ultrasound investigation revealed no signs of intrauterine life in 110 patients. Of these, spontaneous abortion or later evacuation because of missed abortion 101 (histopathological examination showed degenerated villi in 98), not pregnant 4, mola hydatidosa 3, extrauterine pregnancies 2. An ultrasound examination was performed to ascertain whether 136 women with suspected ectopic pregnancy had intrauterine pregnancies. 61 of them had an intrauterine gestational sac, confirmed at clinical follow-up. One of the 61 was operated on with laparoscopy because of pain; no abnormalities were found. In 36 of the other 75, laparoscopy was performed. Ectopic pregnancy 21, ovarian or parovarian cyst 11, adhesions 2, salpingitis 1, and normal 1. Diagnostic ultrasound is excellent for accurate prognosis in threatened abortion. Unnecessary operations avoided; hospitalization in suspected ectopic pregnancies reduced.