B S Mahony

Fetal cystic adenomatoid malformation: Prenatal diagnosis and natural history

We studied the natural history and pathophysiology of congenital cystic adenomatoid malformation (CCAM) detected prenatally by ultrasound in twelve fetuses. Two types of fetal CCAM can be distinguished by gross anatomy, ultrasound findings, and prognosis. Microcystic lesions are usually associated with fetal hydrops and have a poor prognosis (five cases with one survivor). Antenatal diagnosis, maternal transport, and immediate thoracotomy after birth allowed the first reported survival of a newborn with a large microcystic CCAM. Macrocystic lesions are not usually associated with hydrops and have a favorable prognosis (five of seven survived). We conclude that fetuses with hydrops are at high risk for fetal or neonatal demise without intervention. Fetuses with CCAM but without hydrops have a good chance for survival with maternal transport, planned delivery, and immediate neonatal resuscitation and surgery.

Development of an ovarian cancer symptom index

Currently, screening for ovarian cancer is not recommended for the general population. Targeting women with specific symptoms for screening has been evaluated only recently, because it was believed that symptoms had limited specificity.

The clinical significance of uterine leiomyomas in pregnancy

In a retrospective review of 6706 pregnancies between 1981 and 1985, uterine leiomyomas were documented by antenatal sonography in 93 (1.4%) patients. The obstetric records and sonograms of patients with documented leiomyomas were reviewed and compared with data from matched control patients managed at our institution during the same time period. Among the 93 patients with leiomyomas, 14 (15.1%) had one or more leiomyomas subjacent to the maternal surface of the placenta. Significantly, eight of 14 (57%) of these patients with retroplacental leiomyomas subsequently developed abruptio placentae, which resulted in the deaths of four fetuses. Conversely, among the remaining 79 patients whose leiomyomas were not retroplacental, abruptio placentae occurred in only two patients (2.5%), neither of which resulted in fetal death. Clinically significant pain requiring narcotic analgesia developed in 14 of 93 (15.1%) patients and premature labor occurred in 20 of 93 (21.5%); pain and premature labor correlated positively with the size of the largest myoma. Delivery by cesarean section and vacuum assistance occurred significantly more frequently in patients with leiomyomas than in those without documented leiomyomas. In this population uterine myomas did not significantly alter the incidence of intrauterine growth retardation and low Apgar scores.

The “stuck twin” phenomenon: Ultrasonographic findings, pregnancy outcome, and management with serial amniocenteses

Abstract Thirteen consecutive twin pregnancies affected by the “stuck twin” phenomenon were reviewed to determine the potential benefit of serial amniocenteses. The fetal survival rate for the eight pregnancies that underwent serial amniocenteses was 69% (11 of 16 fetuses). This is significantly improved compared with a fetal survival rate of 20% among the five preceding pregnancies managed without serial amniocenteses at the same institution (p = 0.01). It is also markedly improved compared with a combined fetal survival rate of 16% among 48 previously reported pregnancies with the stuck twin phenomenon managed without serial amniocenteses (p

Prenatal sonographic findings of trisomy 18: review of 47 cases.

Prenatal sonographic findings were reviewed in 47 consecutive fetuses with trisomy 18. One or more abnormalities, excluding choroid plexus cysts, were found in 39 fetuses (83%), including 21 of 29 (72%) fetuses examined between 14 and 24 weeks and all 18 (100%) fetuses examined after 24 weeks. Abnormalities most frequently detected before 24 weeks included cystic hygromas, nuchal thickening, and meningomyelocele. Intrauterine growth retardation, cardiac defects, and an enlarged cisterna magna were detected more frequently after 24 weeks than before 24 weeks (P < 0.05). Intrauterine growth retardation was the single most common abnormality, detected in 51% of all fetuses and 89% of fetuses examined after 24 weeks. Choroid plexus cysts were identified in 25% (12 of 47) of fetuses, including 11 of 29 (38%) fetuses seen before 24 weeks. Additional abnormalities were identified in 10 of 12 (83%) fetuses with choroid plexus cysts; one of the two remaining fetuses showed clenched hands and a cardiac anomaly at autopsy, and the other showed unusually large, multiple choroid plexus cysts. Awareness of the type of anomalies and the usual menstrual age of diagnosis in fetuses with trisomy 18 should improve patient counseling and prenatal detection of fetuses considered at risk for this disorder.

Elevated maternal serum α-fetoprotein levels and midtrimester placental abnormalities in relation to subsequent adverse pregnancy outcomes

OBJECTIVE Unexplained elevations of maternal serum alpha-fetoprotein levels in the second trimester of pregnancy are associated with adverse pregnancy outcomes, including intrauterine growth retardation, preterm delivery, preeclampsia, and abruptio placentae. In addition, elevations of maternal serum alpha-fetoprotein have been associated with placental lesions detected during second-trimester ultrasonographic evaluations. We examined the relationship between adverse pregnancy outcomes and unexplained elevations of maternal serum alpha-fetoprotein and placental abnormalities in the second trimester of pregnancy. STUDY DESIGN During the period from January 1989 to March 1991 we conducted a cohort study of 201 women with an elevated maternal serum alpha-fetoprotein (> or = 2.0 multiples of the median) and a second-trimester ultrasonographic evaluation at Swedish Hospital Medical Center and 211 women with normal maternal serum alpha-fetoprotein levels who had also undergone ultrasonographic evaluation at the same institution. All women in this investigation had singleton pregnancies without fetal anomalies. RESULTS Elevated maternal serum alpha-fetoprotein was associated with the following adverse pregnancy outcomes: low birth weight (adjusted risk ratio 3.7), preterm delivery (adjusted risk ratio 3.6), intrauterine growth retardation (adjusted risk ratio 4.0), preeclampsia (adjusted risk ratio 3.8) and abruptio placentae (adjusted risk ratio 4.8). Placental abnormalities detected during second-trimester ultrasonographic evaluations were also associated with adverse pregnancy outcomes: low birth weight (adjusted risk ratio 2.0), preterm delivery (adjusted risk ratio 2.3), intrauterine growth retardation (adjusted risk ratio 1.4), and abruptio placentae (adjusted risk ratio 9.0). A joint positive history of second-trimester elevations of maternal serum alpha-fetoprotein and placental abnormalities was more strongly associated with the following adverse infant outcomes: low birth weight (adjusted risk ratio 6.9), preterm delivery (adjusted risk ratio 5.6), and intrauterine growth retardation (adjusted risk ratio 5.3). CONCLUSIONS Unexplained elevated levels of maternal serum alpha-fetoprotein and placental abnormalities detected in the second trimester of pregnancy are associated with particularly poor pregnancy outcome. Careful examination for placental abnormalities should be part of the evaluation of elevated maternal serum alpha-fetoprotein.

The amniotic band syndrome: Antenatal sonographic diagnosis and potential pitfalls

Amniotic band syndrome causes a variety of fetal malformations involving the limbs, craniofacial region, and trunk. Six prenatally diagnosed cases of amniotic band syndrome are discussed. The diagnosis was based on sonographic visualization of either amniotic sheets or bands associated with fetal deformation or deformities in nonembryologic distributions known to characterize the amniotic band syndrome. Seven additional cases are considered in which an aberrant sheet of tissue with a free edge was visualized within the amniotic cavity but no restriction of fetal motion or subsequent deformity was demonstrated.

Varix of the fetal intra-abdominal umbilical vein: comparison with normal.

To compare the normal extrahepatic portion of the fetal intra‐abdominal umbilical vein (FIUV) with varix of the FIUX, we prospectively measured the diameter of the FIUV in 150 uncomplicated second and third trimester pregnancies and compared these results with retrospective review of nine fetuses with varix of the FIUV as an isolated prenatal sonographic finding. The diameter of the normal FIUV increases linearly from approximately 3 mm at 15 menstrual weeks to approximately 8 mm at term (R = 0.92). The nine fetuses with FIUV varix had a FIUV diameter 6 to 12 standard deviations above the mean for age. Four (44%) of the nine fetuses with FIUV varix subsequently died, including one with trisomy 21. One of the remaining fetuses developed severe hydrops 2 weeks after the initial detection of the FIUV varix. FIUV varix appears to carry an increased risk of adverse fetal outcome, including fetal demise.

Minimal fetal renal pyelectasis.

To assess the possible relationship between the degree of maternal hydration and the sonographic identification of minimal fetal renal pyelectasis, a prospective study was performed in which fetuses demonstrating mild dilation of the renal pelvis (maximum diameter ranging from 3 to 11 mm) were reexamined after the mothers refrained from oral intake for 12 hours. Complete or almost complete resolution of the pyelectasis occurred in only four of 17 kidneys (23.5 per cent) while the remaining fetal kidneys demonstrated little or no change in the degree of pyelectasis following maternal dehydration. This observation, as well as previous experimental research, suggests that the state of maternal oral hydration is not a major cause of minimal fetal pyelectasis. Additionally, the observation of fetal pyelectasis measuring at least 3 mm in greatest dimension is common, occurring in approximately 18 per cent of fetuses older than 24 menstrual weeks.

Sonographic evaluation of ectopic pregnancy.

To assess sonographic findings in the evaluation for ectopic pregnancy, all women referred over a two‐year period were prospectively evaluated. The incidence of intrauterine as well as adnexal findings was assessed in an attempt to optimize sonographic evaluation. Visualization of a double decidual sac sign (DDSS) within the uterus provided an accurate means of confirming an intrauterine pregnancy (IUP) prior to embryo visualization. Forty‐two of 130 women with IUP were diagnosable only by the DDSS. As a screening test for ectopic pregnancy, sonographic documentation of an IUP provided the only convincing evidence for the absence of an ectopic gestation. Any woman clinically at risk for ectopic pregnancy whose sonogram did not confirm the presence of an intrauterine pregnancy was at relatively high risk (43 per cent) for having an ectopic gestation. Characterization of adnexal findings increased the level of risk for ectopic pregnancy in these women to 70‐100 per cent. However, 20 per cent of women with a surgically confirmed ectopic pregnancy had normal adnexal findings.