Bernd K. Wittmann

Fetal Health Surveillance: Antepartum and Intrapartum Consensus Guideline

OBJECTIVE This guideline provides new recommendations pertaining to the application and documentation of fetal surveillance in the antepartum and intrapartum period that will decrease the incidence of birth asphyxia while maintaining the lowest possible rate of obstetrical intervention. Pregnancies with and without risk factors for adverse perinatal outcomes are considered. This guideline presents an alternative classification system for antenatal fetal non-stress testing and intrapartum electronic fetal surveillance to what has been used previously. This guideline is intended for use by all health professionals who provide antepartum and intrapartum care in Canada. OPTIONS Consideration has been given to all methods of fetal surveillance currently available in Canada. OUTCOMES Short- and long-term outcomes that may indicate the presence of birth asphyxia were considered. The associated rates of operative and other labour interventions were also considered. EVIDENCE A comprehensive review of randomized controlled trials published between January 1996 and March 2007 was undertaken, and MEDLINE and the Cochrane Database were used to search the literature for all new studies on fetal surveillance both antepartum and intrapartum. The level of evidence has been determined using the criteria and classifications of the Canadian Task Force on Preventive Health Care. SPONSOR This consensus guideline was jointly developed by the Society of Obstetricians and Gynaecologists of Canada and the British Columbia Perinatal Health Program (formerly the British Columbia Reproductive Care Program or BCRCP) and was partly supported by an unrestricted educational grant from the British Columbia Perinatal Health Program.

Fetal transfusion syndrome: Antenatal factors predicting outcome

Fetal transfusion syndrome is a serious complication of monozygotic multiple pregnancy and is associated with a high perinatal mortality rate. Recent literature has outlined aggressive interventions that attempt to improve the outcome of these pregnancies. We identified 25 cases of fetal transfusion syndrome from 595 multiple pregnancies delivered between January 1983 and December 1987 at the Grace Hospital. Analysis of antenatal factors with respect to survival showed that gestational age at delivery, the presence of hydrops, and the use of decompression amniocentesis may help in predicting outcome. These factors may be useful in deciding on the appropriate therapeutic approach for a particular pregnancy.

Plasma carnitine in pregnancy

Plasma levels of total and free carnitine and acylcarnitine were determined in women pregnant for 28 to 42 weeks, and also in some of their fetuses. The finding was that the levels not only of free but also of total carnitine were very low in pregnancy. They were somewhat elevated in women with essential hypertension. Levels of acylcarnitine were significantly decreased in gestational diabetics, presumably because these women were treated with insulin. In nine cases examined, plasma levels of total and free carnitine and acylcarnitine were significantly higher in the fetuses than in their mothers.

Selective Feticide in Twin Transfusion Syndrome Using Ultrasound-Guided Insertion of Thrombogenic Coils

Twin transfusion syndrome is a common complication of monozygotic twin pregnancies. Selective feticide is one of the many different aggressive and invasive therapies that has been suggested to improve an otherwise dismal perinatal outcome. The ideal method of selective feticide remains to be delineated for cases of twin transfusion syndrome that occur remote from term. We describe a case involving the use of intracardiac placement of thrombogenic coils to attempt selective termination.

Ultrasound fetal biometry charts for a North American Caucasian population

This study was done to produce enhanced fetal biometry charts and graphs presenting percentile values as a function of fetal age.

The value of diagnostic ultrasound as a screening test for intrauterine growth retardation: Comparison of nine parameters

In an attempt to devise a screening method for the detection of unsuspected IUGR, a battery of ultrasonic measurements of the fetus were performed in a series of 255 patients at approximately 32, 34, and 36 weeks. The results obtained from the 16 growth-retarded and the 239 normally grown babies were evaluated. While no single measurement was found to discriminate the two groups, a simple combination of crown-rump length times area of trunk allowed us to identify an at-risk group comprising 11 per cent of the population. The false positive and false negative results were acceptable at levels of 10 and 6 per cent, approximately. It is considered that these results would justify a larger and prospectively randomized controlled trial to assess the benefits and drawbacks of applying these measurements in a screening schedule.

Management of quintuplet pregnancy by selective embryocide

Selective embryocide was performed as a two-stage procedure in a patient with a quintuplet pregnancy in the first trimester. No complications occurred, and the patient was delivered of healthy twins at term. This procedure may be offered to selected patients with pregnancies with greater than five embryos.

Antenatal invasive and noninvasive management of alloimmune thrombocytopenia

The outcome analysis of 10 pregnancies at risk for neonatal alloimmune thrombocytopenia (NAIT) is presented. An experimental protocol of cordocentesis and maternal administration of intravenous immunoglobulin (IVIG) is compared to a control group of older untreated affected siblings. The outcome in pregnancies treated with IVIG shows improved fetal platelet count in 70% and no intraventricular hemorrhage. We conclude that maternal administration of IVIG appears to improve clinical outcome in fetuses at risk for NAIT.

Fetal weight estimation by real-time ultrasound measurement of biparietal and transverse trunk diameter

Measurements of biparietal diameter and transverse trunk diameter with the use of linear array real-time B-mode scanning were performed on 100 fetuses within 72 hours of delivery to evaluate the reliability of Hansmann and associates, nomogram in predicting fetal weight. Under optimal conditions, 82% of predicted birth weights were within 10% of actual birth weight with a mean error of 150 gm (6%) and a correlation coefficient of 0.98. Predictions were most accurate in fetuses weighing less than 1,500 gm and in the 2,000 to 4,000 gm group and were least accurate in the infant weighing less than 1,500 gm and in the 2,000 to 4,000 gm group and were least accurate in the infant weighing more than 4,000 gm. Once the accuracy of the method was determined, It was applied to 100 consecutive cases to evaluate the feasibility of this technique in clinical practice. Measurements were unobtainable in 15%, but in the remainder, predictions were of sufficient accuracy throughout the range of fetal weights to complement clinical assessment in the management of high-risk pregnancies. Seventy-four percent of predicted weights were within 10% of actual birth weight; the mean error was 165 gm (7.2%) and the correlation coefficient was 0.97.

Pathology of Intragestational Intervention in Twin-to-twin Transfusion Syndrome

Selective intervention in multiple pregnancy is being used to enhance the chances of survival of at least one conceptus when the risks for the combined conceptuses and mother are considered too great. These procedures have been applied to induced polyembryonic conceptions (selective continuance) and discordant dichorionic twins (selective birth). We report attempts at selective intervention in three monochorionic twin gestations affected by twin-to-twin transfusion syndrome. In all three cases, both fetuses seemed doomed and the mother was in significant distress. The selected survivor in the first case is doing well; both twins were stillborn in the second case; in the third case, the selected survivor died as a neonate but the other twin survived and is doing well. We suggest possible explanations for the clinical outcome of each case based on detailed pathologic examination of the delivered placentas and autopsy examination of the nonsurviving twins. The shared chorionic circulation is the source of both the clinical disorder and the potential complications of any attempt to alleviate the disorder. This situation is unique to monochorionic twins, and we discuss the implications of this for intrauterine therapy of twin-to-twin transfusion syndrome.