Abdallah Adra

Pregnancy outcome in spontaneous twins versus twins who were conceived through in vitro fertilization

OBJECTIVE The purpose of this study was to compare maternal and neonatal complications in spontaneous versus in vitro fertilization twins. STUDY DESIGN Twin gestations that were delivered from 1995 to 2000 were reviewed. Cases consisted of 56 in vitro fertilization twins, each of which was matched to two control mothers by age and parity. They were compared regarding various maternal and neonatal complications. RESULTS In vitro fertilization twins were more likely to have preterm labor compared with control twins, with no difference in the incidences of pregnancy-induced hypertension, gestational diabetes mellitus, placenta previa, or preterm premature rupture of membranes between the two groups. The cesarean delivery rate was significantly higher in cases of twins who were conceived by in vitro fertilization (76.8% vs 58.0%, P=.026), despite a similar rate of elective cesarean delivery and the incidence of nonvertex twin A in both groups. The preterm delivery rate was significantly higher (67.9% vs 41.1%, P=.002) and the gestational age was significantly lower (35+/-3 weeks vs 36+/-3 weeks, P=.043) in cases compared with control subjects. Both twins were, on the average, 230 g lighter in the in vitro fertilization group compared with the control group. However, intrauterine growth restriction was more frequent in the control group (36.6% vs 25%, P=.044). There was a significantly higher incidence of admission to the neonatal intensive care unit, respiratory distress syndrome, a need for mechanical ventilation, and pneumothorax in cases compared with control subjects. CONCLUSION When compared with spontaneous twins, in vitro fertilization twins are more likely to be delivered by cesarean delivery and to have a higher incidence of preterm birth and prematurity-related respiratory complications with a longer nursery stay.

The fetus with gastroschisis: Impact of route of delivery and prenatal ultrasonography

OBJECTIVES Our purpose was (1) to assess the influence of delivery route on neonatal outcome in fetuses with gastroschisis and (2) to correlate ultrasonographic appearance of fetal bowel with immediate postnatal outcome. STUDY DESIGN Forty-seven cases (1986 to 1994) were reviewed; three abortions and two stillbirths were excluded. Ultrasonographic appearance of fetal bowel (small bowel dilatation > 10 mm) was evaluated in 27 cases. RESULTS Twenty-six infants (61.9%) were delivered vaginally and 16 (38.1%) by cesarean section (11 elective, 5 in labor). Delivery route was not significantly associated with indicators of neonatal outcome (rate of primary closure, postoperative complications, days of parenteral nutrition, days to oral feeding, hospital days, or mortality). When ultrasonographic appearance of fetal bowel was correlated with outcome, fetuses with prenatally dilated bowel had significantly more bowel edema at birth (p=0.038), longer operative time (p=0.013), and higher overall rate of postoperative complications (p=0.037). CONCLUSIONS (1) Elective cesarean delivery does not improve neonatal outcome in infants with gastroschisis. (2) Abnormal ultrasonographic appearance of fetal bowel is associated with a more difficult repair and a higher overall incidence of postoperative complications.

Ultrasonographic diagnosis of fetal seizures: a case report and review of the literature.

Sir, I read with interest the article by Usta et al.1 regarding the sonographic diagnosis of fetal seizures. It is useful that the authors not only described their findings but also illustrated them with a video clip. However, motor assessment can be optimised further. The authors state that ‘Although relatively inactive, the fetus developed sudden jerky body movements like a startle reflex and episodes of repetitive movements of the upper extremities interpreted as seizures’. I would like to point out that the relative inactivity may also be of major importance for diagnosis. Inactivity and activity can be quantified provided the observation period is specified. Normal values are established for various movement patterns not only for general movements but also for startles.2 The authors did document that startle-like movements occurred over almost 12 minutes but did not report during which period of observation the relative inactivity was examined. Second, the description of ‘relatively inactive’ is not specific because the authors did not state which movement patterns were lacking or within which movement pattern activity was limited. Absence of general movements on its own is a sign of disturbed integrity of the central nervous system, not only quantitatively but also qualitatively, for example reduced variation in speed, amplitude, participation of body parts and the direction in which these body parts move. The combination of reduced activity with abrupt movements as reported here has been published before. In a recent review on abnormal fetal motor activity, 36 fetuses with fetal akinasia deformation sequence were reported.3 All fetuses performed reduced qualitative and/or quantitative motor activity, but four fetuses also had abrupt movements and one even had seizures.3 Similar abrupt movements have also been reported by Skupski et al.4 The authors did not elaborate on the possible underlying cause in the fetus. The combination of the findings of polyhydramnios, nonvisualised stomach filling, clenched fist and micrognathia in relation to relative inactivity despite the seizure-like activity suggests an underlying disease, such as the fetal akinesia deformation sequence. The majority of these sequences have an autosomal recessive underlying disorder, which cannot yet be diagnosed antenatally by invasive genetic testing. Therefore, it should be a part of counselling that diagnosis in future pregnancies is still dependent on sonographic examination. The reported lissencephaly and mild ventriculomegaly should also stimulate consideration of other conditions that can be diagnosed by invasive testing, for example the Zellweger syndrome. Systematic motor assessment should be performed in all cases suspected to have involvement of the central nervous system, including quantification of movement and qualitative description of specific movement patterns during a known observation period and examination of the posture of the extremities. Evaluation with a geneticist for possible underlying diagnosis and possibilities for invasive antenatal diagnosis in future pregnancies is advised. In the absence of invasive diagnostic possibilities, motor and postural examination should start during the first trimester of pregnancy. j

Primary infertility associated with isolated cervical collecting diverticulum

OBJECTIVE To describe a previously unreported isolated congenital cervical diverticulum and its gynecologic, reproductive, and obstetrical implications. DESIGN Case report. SETTING A university hospital. PATIENT A 31-year-old woman presenting with menometrorrhagia and primary infertility. Investigation revealed an isolated collecting cervical diverticulum causing prolonged postmenstrual spotting, possibly interfering with sperm capacitation and access to the uterine cavity. INTERVENTION(S) The examination included hysterosalpingography and magnetic resonance imaging. The combined hysteroscopy and laparoscopy revealed a 5 x 5 cm cervical diverticulum, around 1 cm from the external cervical os, leading to a short cervical canal connected to a normal uterine cavity. The patient achieved a pregnancy after controlled ovarian hyperstimulation and ultrasonographically guided intrauterine insemination. MAIN OTUCOME MEASURE(S): Pregnancy and obstetrical outcome. RESULT(S) Extensive evaluation revealed the patients condition to be a previously undescribed congenital cervical anomaly. The patients infertility was corrected by ovulation induction and sonographically guided intrauterine insemination, which resulted in a twin pregnancy. After 27 weeks of gestation, preterm labor complicated the delivery. CONCLUSION(S) The diagnosis and management of this unusual congenital cervical diverticulum present a particular challenge, as this congenital abnormality has not been previously described or reported.

Prescribing practices among Lebanese obstetricians for prenatal corticosteroids to enhance fetal lung maturity

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