Alessandro Ghidini

Clinical outcome of mild fetal ventriculomegaly

OBJECTIVE Our purpose was to evaluate the outcome of fetuses with mild cerebral ventriculomegaly. STUDY DESIGN We prospectively collected all cases of mild cerebral ventriculomegaly (transverse diameter of the atrium of the cerebral lateral ventricles between 10 and 15 mm) diagnosed antenatally between January 1990 and December 1996. Associated ultrasonographic abnormalities including markers of aneuploidy, presence of chromosomal anomalies, structural malformations detected at birth, and neurologic outcome were recorded. Outcome information was available on all cases. In addition, published series of cases of fetal mild cerebral ventriculomegaly were reviewed to identify prognostic indicators. RESULTS Eighty-two cases fulfilled the inclusion criteria: 48 were isolated and 34 were associated with other ultrasonographic markers or anomalies. Among the 45 surviving euploid isolated cases, neurologic follow-up was normal at a mean age of 28 months (range 3 to 72 months). Male fetuses and those with a transverse atrial size <12 mm had a good prognosis. Ventricular atria > or =12 mm were more often associated with other anomalies (56% vs 6%) and, when isolated, with abnormal postnatal neurodevelopment (23% vs 3%). Aneuploidy was present in two cases of isolated mild cerebral ventriculomegaly, both of which were associated with advanced maternal age, and in seven cases associated with other anomalies. CONCLUSIONS Mild cerebral ventriculomegaly should prompt targeted ultrasonographic examination, inclusive of markers of aneuploidies, visualization of the corpus callosum, and echocardiogram as well as serologic evaluation for congenital infections. In isolated mild cerebral ventriculomegaly genetic counseling should take into account clinical, laboratory, and ultrasonographic findings. A review of the published series suggests that cognitive or motor delay is predominantly mild and that it occurs in about 9% of cases of isolated mild cerebral ventriculomegaly.

Risk factors for pulmonary hypoplasia in second-trimester premature rupture of membranes

OBJECTIVE Our purpose was to determine the independent contribution of gestational age at rupture of membranes, latency period, and severity of oligohydramnios to the prediction of pulmonary hypoplasia in patients with second-trimester premature rupture of membranes. STUDY DESIGN All women with premature rupture of membranes at < 28 weeks diagnosed between January 1982 and December 1990 were managed conservatively with a consistent protocol until intrauterine death or spontaneous or induced delivery. The diagnosis of pulmonary hypoplasia was made by strict pathologic and radiographic criteria. RESULTS A total of 63 patients fulfilled the inclusion criteria. Pulmonary hypoplasia was present in 15 cases: two of nine stillborns, 12 of 25 neonatal deaths, and one of 24 survivors. All fetuses with pulmonary hypoplasia had oligohydramnios. Univariate analysis showed that the occurrence of pulmonary hypoplasia was significantly associated with gestational age at premature rupture of membranes (p = 0.002), oligohydramnios during the latency period (p = 0.005), and duration of the latency period (p = 0.02). However, logistic regression analysis showed that only the first two variables were independent predictors of pulmonary hypoplasia. CONCLUSION Gestational age at premature rupture of membranes and oligohydramnios are independent predictors of the occurrence of pulmonary hypoplasia.

Obstetric cholestasis: outcome with active management

Abstract Objective: Conservative management of intrahepatic obstetric cholestasis is associated with a high stillbirth rate despite monitoring of fetal well-being with non-stress test and amniotic fluid volume assessment. Most cases of stillbirth are associated with meconium passage. We prospectively evaluated the effect of a management protocol inclusive of surveillance for presence of meconium and induction of labor at 37 weeks. Study Design: Between January 1989 and December 1997, all women with obstetric cholestasis underwent transcervical amnioscopy after 36 weeks for assessment of amniotic fluid color, in addition to standard monitoring of fetal well-being (semi-weekly non-stress test and amniotic fluid volume determinations). Amniocentesis for fetal lung maturity and amniotic fluid color assessment was performed before 36 weeks in severe cases. Labor was induced at 37 weeks or earlier in the presence of non-reassuring fetal testing, meconium, or severe maternal symptoms unresponsive to therapy with mature fetal lungs. The obstetric outcome of the group with cholestasis was compared with that of the general obstetric population at our Institution during the study period. The rate of fetal death in the study group was compared with that of series published within the last 20 years, which used expectancy and conventional monitoring of fetal well-being. Statistical analysis utilized Fisher’s exact test, Chi-square, and Student’s t-test with P value

Idiopathic fetal growth restriction: a pathophysiologic approach.

Known causes of fetal growth restriction (FGR) can be traced in up to 40 percent of the cases. In the remainder of cases, FGR is idiopathic in origin. Evidence from experimental studies, antenatal findings at Doppler velocimetry of the uterine and umbilical arteries, and placental pathology studies suggests that idiopathic FGR can be divided into three groups: 1) primary abnormality in the uteroplacental perfusion; 2) primary abnormality in the fetoplacental perfusion; and 3) abnormal villous structure at the interface between fetal and maternal circulation. An improved understanding of the pathophysiology of idiopathic FGR is crucial to gain insight into its pathogenesis.

A randomised controlled trial of ursodeoxycholic acid and S-adenosyl-l-methionine in the treatment of gestational cholestasis

Objective  To compare the efficacy of S‐adenosyl‐l‐methionine and ursodeoxycholic acid in improving serum biochemical abnormalities in gestational cholestasis.

The risk of second-trimester amniocentesis in twin gestations: A case-control study

OBJECTIVE Pregnancy outcomes in patients with twin pregnancy undergoing second-trimester amniocentesis for fetal karyotype assessment were compared in a case-control study with twin pregnancies undergoing routine ultrasonographic studies at similar gestational ages. STUDY DESIGN All spontaneous and induced twin gestations that underwent ultrasonographic examination between 14 and 20 weeks were compiled for the period January 1987 through January 1992. Patients having undergone multifetal reduction or chorionic villous sampling and those with fetal anatomic or chromosomal anomalies, discordant growth (> 20%), death, or a monoamniotic sac detected at ultrasonography were excluded. RESULTS The mean (+/- SD) maternal age was significantly higher among the 101 cases than among the 108 controls (35.2 +/- 3.5 vs 30.4 +/- 5.3 years, respectively; p < 0.01). No differences were noted in gravidity, parity, number of prior spontaneous losses, or gestational age at ultrasonography between the two groups. The fetal loss rate was similar among cases and controls (seven of 202 [3.5%] vs seven of 216 [3.2%], relative risk 1.07, 95% confidence intervals 0.3 to 3.5). No losses occurred within 3 weeks of the procedure. Gestational age at delivery, birth weight, mean Apgar scores at 1 and 5 minutes, and length of neonatal stay were not significantly different between cases and controls. CONCLUSIONS Second-trimester amniocentesis in twin pregnancies is apparently not associated with excess pregnancy loss.

Prognostic factors for successful expectant management of ectopic pregnancy

OBJECTIVE To determine the independent ability of initial hCG titers, trend of hCG titers, and ultrasonographic findings in the prediction of successful expectant management in ectopic pregnancy (EP). DESIGN Case-control study. SETTING University hospital. PATIENTS Sixty-seven patients with EP managed expectantly, 49 of whom (73%) had a spontaneous resolution, whereas 3 (5%) underwent medical treatment, and 15 (22%) eventually underwent surgical treatment. RESULTS Univariate analysis showed that the initial hCG titer, the trend in hCG titers between first and second sample, and ultrasonographic visualization of absence of an ectopic gestational sac were significant predictors of a successful expectant management. Using receiver operating characteristic curve analysis, an hCG titer < 1,000 mIU/mL was chosen as the optimal cutoff for this prediction, identifying 88% of women destined to have spontaneous resolution of the EP. Multivariate analysis showed that both initial hCG titer and trend in hCG titers but not ultrasonographic visualization of an ectopic gestational sac were independent predictors of a successful or failed expectant management. CONCLUSION Expectant management of EP is successful in the majority of patients with initial hCG titer < 1,000 mIU/mL.

Screening for congenital heart disease with the four-chamber view of the fetal heart

OBJECTIVE Our objective was to determine the efficacy of the four-chamber view of the fetal heart in routine ultrasonographic examination as a screening tool for congenital heart defects. STUDY DESIGN A prospective cohort study compared the detection rate of congenital heart defects among 5336 pregnant women screened with the ultrasonographic four-chamber view of the fetal heart from 1987 through 1989 with that among 3680 patients examined ultrasonographically without the four-chamber view during the 2 preceding years (1985 through 1986). All patients were followed until delivery or termination of pregnancy, and clinical or autopsy confirmation of prenatal findings were obtained on all cases. RESULTS The overall incidence of congenital heart diseases was 5.2 per 1000 (47/9016). During the years 1985 through 1986 15 neonates with congenital heart diseases were identified, seven of which were prenatally diagnosed (sensitivity 43%). During the period 1987 through 1989 a four-chamber view of the fetal heart was obtained in 95% of cases; 32 cases of congenital heart disease occurred, 26 of which were diagnosed antenatally (sensitivity 81%; p = 0.01). Two false-positive diagnoses were made during the second time period, giving a specificity of 99.9%. CONCLUSION The four-chamber view of the fetal heart is easily obtained, does not significantly increase the duration of a routine ultrasonographic examination, and has an excellent sensitivity for the identification of congenital heart diseases.

Prognostic indicators in the prenatal diagnosis of agenesis of corpus callosum

OBJECTIVE Our aim was to determine the accuracy of ultrasonography in the prenatal diagnosis of agenesis of the corpus callosum and to establish whether ultrasonography can provide prognostic indicators in cases of agenesis of the corpus callosum. STUDY DESIGN Prospective ultrasonographic study of the corpus callosum in all cases during an 8-year period in which fetal cerebral ventriculomegaly was detected. RESULTS A total of 14 cases of agenesis of the corpus callosum are reported. In seven cases agencies of the corpus callosum was an isolated finding, and in seven cases it was associated with other abnormalities. Six cases involved mendelian syndromes (3 Lissencephaly syndrome, 2 Aicardi syndrome, and 1 Andermann syndrome), and one case was associated with trisomy 13. In 5 of 14 fetuses, all male, agenesis of the corpus callosum was an isolated benign finding. The corpus callosum could never be visualized before midgestation, but diagnosis of agenesis of the corpus callosum was very accurate after 20 weeks. CONCLUSION Prenatal ultrasonographic findings suggestive of agenesis of the corpus callosum should be followed by a careful search for associated anomalies that may indicate genetic syndromes. Isolated agenesis of the corpus callosum is often an isolated, benign finding, particularly in male fetuses. In families at risk for mendelian syndromes associated with agenesis of the corpus callosum, lack of visualization of this structure is suggestive of the diagnosis.

Natural history of uterine leiomyomas in pregnancy.

A prospective study was conducted over a 6 year period to determine the natural history of uterine leiomyomas in pregnancy. All pregnant women with myomas detected during obstetric ultrasonographic examination and with three or more sonographic examinations were included; 134 patients fulfilled the inclusion criteria. Sonograms were obtained at 2 week intervals until 20 weeks of gestation, and monthly thereafter. The following observations were made: (1) the majority of myomas 5 cm or less in average diameter could no longer be seen during pregnancy; (2) the majority of myomas greater than 5 cm in diameter tended to remain stable or decrease in size during pregnancy; and (3) multiple myomas were less likely to disappear than solitary myomas.