A. Abbas

Fetal renal defects: associated malformations and chromosomal defects.

During a 6-year period (1985-1990) blood karyotyping was performed in 682 fetuses with renal defects. There were: 276 fetuses with mild hydronephrosis; 206 with moderate/severe hydronephrosis; 173 with multicystic dysplasia, and 27 with renal agenesis. The overall incidence of chromosomal abnormalities was 12% (trisomies, n = 63; deletions, n = 9; triploidies, n = 5, and sex chromosome aneuploidies, n = 8). There were more than twice as many males than females, but the incidence of chromosomal defects in females was almost double (18%) than in males (10%). Furthermore, compared to the overall maternal age-related risk, the risk for fetal chromosomal abnormalities was three times higher when there was an isolated renal defect and thirty times higher when there were additional malformations. The risk of chromosomal abnormalities was similar for fetuses with unilateral or bilateral involvement, different types of renal defects, urethral or ureteric obstruction, and oligohydramnios or normal/reduced amniotic fluid volume. Nevertheless, the patterns of chromosomal abnormalities, and consequently that of associated malformations, were related to the different types of renal defects.

Maternal alpha‐fetoprotein levels in multiple pregnancies

of induced abortions (25.9 YO) and a lower proportion of deliveries (66.8 YO) than did the PACA region : 233 YO and 68.7 %, respectively. However, no significant differences were seen in the proportion of spontaneous abortion (6.3 % vs 6.8 YO) and ectopic pregnancy (1 %). Age adjustment (direct method) did not modify our findings. Combining the results of the two regions, the rate of spontaneous abortion (defined as the proportion of spontaneous abortions among all the pregnancies) was 6.5 % and increased with age (5.1 YO in women aged 15 to 19 years to 15.7% in women aged 40 to 44 years). The incidence of ectopic pregnancy was 1 YO and varied from 0.6 YO in the youngest age groups (15 to 19 years and 20 to 24 years) to 1.8% (35 to 39 years) and 1.3% (40 to 44 years). Since our survey included almost all medical centres and thus nearly all women at the end of pregnancy, the results provide a good estimate of the number of pregnancy outcomes. However, women who had a very early spontaneous abortion were not included since they would not usually be admitted to hospital. The comparison with studies published since 1980 is difficult due to different denominators. However, the rate of spontaneous abortion (6.5 YO) in our study is lower than that (10.2 YO) found in 1983 in the Finnish nationwide database (Lindbohm & Hemminki 1988), but ectopic pregnancies were not included in the denominator. The incidence rate of ectopic pregnancy (1 YO) in our study is close to that reported in 1983 in the United States (14/1000 reported pregnancies) (Centers for Disease Control 1986) but spontaneous abortions were not included. The major strength of our study was to record all pregnancy outcomes over defined periods in large geographical sites in order to estimate better the true denominator. Repetition of the study with the same methodology will provide trends in the rates of pregnancy outcomes. Furthermore, the development of similar studies planned in Europe will allow valid between-country comparisons in rates of pregnancy outcomes.

Superovulation, IGFBP-1 and birth weight

In this study, the effect of superovulation on the circulating levels of insulin-like growth factor binding protein-1 (IGFBP-1) has been investigated. IGFBP-1 levels were measured in singleton pregnancies achieved either naturally (n = 203) or following superovulation, in-vitro fertilisation and embryo transfer (IVF-ET) with either pituitary desensitisation with buserelin and superovulation with human menopausal gonadotrophin (b/hMG) followed by IVF-ET (n = 15) or with clomiphene citrate and hMG (CC/hMG) followed by IVF-ET (n = 15, 1st trimester only). The circulating levels of IGFBP-1 were similar in all three groups during the first trimester, and in both normal and b/hMG pregnancies in the second, but were significantly higher during the third trimester in b/hMG pregnancies than in normal pregnancies (P = 0.0002). The birth weights were significantly lower in the b/hMG group (P = 0.04), but not in the CC/hMG group compared with natural conceptions. Gestational age at delivery was similar in control and b/hMG pregnancies, but significantly reduced in CC/hMG pregnancies (P = 0.04). These data suggest that pregnancies achieved following superovulation with b/hMG are associated with elevated levels of IGFBP-1 during the third trimester of pregnancy and reduced birth weight.

Fetal and maternal hCG concentration in aneuploid pregnancies

Correspondence: Professor K. H. Nicolaides, The Harris Birthall cases cordocentesis was performed because ultrasound examination identified fetal dysmorphic features (Nicolaides er al. 1992). Each of these sera was matched for gestation with a fetal and maternal blood sample from a chromosomally normal singleton pregnancy. Gestational age was determined from the menstrual history and was confirmed by an ultrasound scan in early pregnancy. All fetal blood samples were obtained by cordocentesis. Kleihauer testing confirmed that all blood samples were of fetal origin. Maternal venous blood was collected from the

Fetal Blood Ferritin and Cobalamin in Normal Pregnancy

In a cross-sectional study of 75 singleton pregnancies at 16-38 weeks gestation serum cobalamin and ferritin concentrations were measured in fetal and maternal blood samples. Fetal serum cobalamin concentration did not change significantly with gestation but ferritin concentration increased. The median fetal serum concentrations of both ferritin and cobalamin were significantly higher than the respective values in the mother. The median fetal-maternal ratio for ferritin was 3.2 and for cobalamin 1.2. These findings demonstrate that from at least 16 weeks gestation, there is efficient iron storage in the fetus and transfer of cobalamin from the mother to the fetus against a concentration gradient.

Serum ferritin and cobalamin in growth retarded fetuses

Objective To examine fetal and maternal serum cobalamin and ferritin concentrations in pregnancies complicated by fetal growth retardation.

Fetal Serum Ferritin and Cobalamin in Red Blood Cell Isoimunisation

Fetal and maternal serum ferritin and cobalamin concentrations were examined in 40 red blood cell-isoimmunised pregnancies undergoing cordocentesis at 18-38 weeks of gestation and the values were compared to those of normal pregnancies. In the red blood cell-isoimmunised pregnancies, the fetal serum ferritin concentration was increased and the cobalamin concentration was decreased, whereas maternal serum ferritin was decreased and cobalamin was not significantly different from normals. There was a significant association between the degree of fetal anaemia and the increase in fetal serum ferritin concentration, but not with fetal serum cobalamin. This study suggests that fetal haemolytic anaemia is associated with iron overload and cobalamin deficiency.

The Fetus as a Patient

A 19-WEEK PARTURIENT presented with a fetus with a lung mass. Magnetic resonance imaging (panel A) demonstrated a congenital cystic adenomatous malformation (CCAM) occupying the right chest causing mediastinal shift, cardiac compression (H heart), and displacement of the hemidiaphragm (arrow). Both lungs were compressed. Hydrops fetalis was present (A fetal ascites; B bowel; L liver). Echocardiography revealed a compressed but structurally normal heart. The hydrops improved after aspiration, but the macrocyst recurred and the solid component continued to enlarge. A thoracoamniotic shunt was placed for continuous drainage. Imaging at 36 weeks (panel B) demonstrates the right hemidiaphragm in the correct position and resolution of the fetal ascites. Lung hypoplasia and mediastinal shift necessitated mass resection during ex utero intrapartum therapy. A maternal laparotomy was performed, followed by hysterotomy allowing delivery of the fetal head, chest, and arm. High-dose volatile anesthetic (2 minimum alveolar concentration of desflurane) provided uterine relaxation and fetal anesthesia. Maternal blood pressure was maintained with phenylephrine. Intramuscular fetal injections included fentanyl (20 g/kg), vecuronium (200 g/kg), and atropine (20 g/kg). The fetus was intubated (not ventilated), and pulse oximeter and peripheral venous access were established. After pulmonary lobectomy, the fetus was ventilated and delivery and newborn resuscitation were completed. Congenital cystic adenomatous malformation results from overgrowth of terminal bronchial epithelium. Mass effect results in pulmonary hypoplasia. Cardiac compression with impaired venous return leads to lethal cardiac failure (hydrops). Maternal health is threatened, asa state similar topreeclampsia (maternalmirror syndrome)mayensue. Exutero intrapartumtherapyprocedure isa feasibleandpotentially a life-saving treatment for congenital cystic adenomatous malformation. It provides time on uteroplacental gas exchange for controlled resection of the large fetal lung mass. The anesthetic goals for ex utero intrapartum therapy procedure include achieving uterine hypotonia, usingdeepgeneralanesthesiaornitroglycerin, tomaintainuteroplacentalcirculation;avoidingpostpartumhemorrhage;maintainingnormal maternal blood pressure often requiring -adrenergic agonist support; and achieving surgical anesthesia for the fetus to avoid first breathing while avoiding fetal cardiac depression.

Fetal Plasma Tumor Necrosis Factor Concentration in Normal Pregnancy

The aim of the study was to investigate changes with gestation of fetal plasma tumor necrosis factor alpha (TNF-alpha) concentration. In a cross-sectional study, enzyme-linked immunoassay was used to measure plasma TNF-alpha concentration in 40 fetal blood samples obtained by cordocentesis (n = 25), cardiocentesis (n = 5) or at elective caesarean section (n = 10) at 12-38 weeks gestation. The fetal plasma concentration of TNF-alpha increased from a mean of 13.5 pg/ml at 12 weeks gestation to 37.5 pg/ml at 38 weeks (r = 0.59, p < 0.0001), and was significantly associated with the monocyte count (r = 0.56, p < 0.001). TNF-alpha is present in the fetal circulation from at least 12 weeks and the changes in plasma TNF-alpha concentration with gestation coincide with the development of the fetal monocyte-macrophage system.