Catherine A. Walla

Antepartum fetal heart rate testing

Abstract Antepartum fetal heart rate testing (AFHRT) was utilized in the assessment of fetal status on a large clinical service. The nonstress test (NST) was used as the primary approach. The contraction stress test (CST) was used in the face of persistent nonreactivity. The significance of fetal bradycardia occurring during AFHRT was assessed. Bradycardia was defined as a fetal heart rate (FHR) of 90 bpm or a reduction in FHR of 40 bpm below baseline, for 60 seconds or greater. In a 2-year period, there were 28 cases of bradycardia during 3,754 tests. A total of 24 cases were sent for delivery on the same day while four cases were managed in variable fashion. In 16 cases the tests were classified as nonreactive (abnormal) and the patients were sent for delifery on the same day. There was a 50% incidence of emergency delivery for fetal distress in labor in this group. In eight cases the tests were classified as reactive (normal) and the patients were sent for delivery on the same day. The incidence of fetal distress in labor with emergency delivery was 50%. Five of 10 patients with decreased amniotic fluid volume either on ultrasonic evaluation or by clinical estimation developed fetal distress in labor. There were three cases of congenital anomalies and one case of intrauterine growth retardation which exhibited diminished amniotic fluid. The occurrence of fetal bradycardia during AFHRT denotes a fetus at increased risk of developing fetal distress in labor. This type of test should be considered abnormal and consideration should be given to delivery of the fetus.

A multidisciplinary approach to the early detection of ovarian carcinoma: Rationale, protocol design, and early results

OBJECTIVE This study was undertaken to determine the feasibility of currently available tests to detect ovarian cancer at a curable stage. By studying women at risk for the disease on the basis of their family histories of cancer, we hope to gain insight into the genetics and biologic characteristics of ovarian cancer. STUDY DESIGN Asymptomatic women with a family history of cancer are interviewed by geneticists to obtain accurate pedigree and epidemiologic data. Screening tests including transvaginal ultrasonography, color Doppler imaging, CA 125 measurement, and other investigative biomarkers are performed between cycle days 3 and 8 and repeated biannually. RESULTS A total of 597 women without symptoms were screened between July 1991 and June 1992. Cystic or complex adnexal masses were detected in 6.2% of patients. A pulsatile index value < 1.0 was measured in 80% of premenopausal patients and 24% of postmenopausal patients, whereas a resistance index value < 0.4 occurred in 12% of premenopausal and 3% of postmenopausal patients. A CA 125 level > 35 U/ml was found in 11.4% of the study participants. To date, one stage IA borderline ovarian tumor and one endometrial carcinoma have been found. CONCLUSIONS Ovarian cancer screening needs to be investigated in a controlled fashion to determine means that will ultimately improve the survival from the disease.

Maternal phenylketonuria collaborative study, obstetric aspects and outcome: The first 6 years

Objective: The purpose of this study was to evaluate the efficacy of a phenylalanine-restricted diet in reducing fetal morbidity associated with maternal hyperphenylalaninemia in women of childbearing age with blood phenylalanine levels >240 μmol/L (>4 mg/dl) on an unrestricted diet. Study Design: Two hundred thirteen pregnant women with hyperphenylalaninemia that resulted in 134 live births have been enrolled in the study. Outcome measures were subject to the χ 2 test, Fisher exact test, analysis of variance, t test, or Wilcoxon nonparametric test for analysis. Results: Optimal fetal outcome appeared to occur when blood phenylalanine levels Conclusions: Preconceptual counseling and early entrance into a prenatal care program is essential in achieving optimal fetal outcome in women with hyperphenylalaninemia.

Three-dimensional ultrasonography in obstetrics and gynecology: Preliminary experience☆☆☆★★★

OBJECTIVE Technologic advances in ultrasonographic imaging have revolutionized the management of womens health care. We recently began to evaluate the clinical applications of three-dimensional ultrasonography. STUDY DESIGN This study prospectively evaluated 161 obstetric and gynecologic patients. Both two- and three-dimensional imaging data were acquired from real-time ultrasonography. Three orthogonal planes were displayed on a monitor and were used to create the rendered three-dimensional images. RESULTS To date, 201 three-dimensional ultrasonographic studies have been performed, 165 transabdominally and 36 transvaginally. Transabdominally, an average of eight acquisitions per patient were obtained. Of the clinically suspected abnormalities, 29 of 32 (91%) were confirmed by three-dimensional imaging. Three of 32 (9%) improved the diagnostic capabilities or changed the diagnosis. Of the 36 transvaginal studies, an average of four acquisitions per patient were done. Thirty (83%) of these patients had suspected abnormalities and all were confirmed. CONCLUSIONS Three-dimensional ultrasonographic imaging appears to be highly promising in the clinical setting.

The role of nonstress tests, fetal biophysical profile, and contraction stress tests in the outpatient management of insulin-requiring diabetic pregnancies

Antepartum fetal surveillance methods applicable in a home glucose-monitored population of pregnant diabetic women have been evaluated. A testing sequence of nonstress heart rate testing, backed up by either the fetal biophysical profile or contraction stress testing employed at a twice weekly interval, in 107 outpatients was compared with the management of 140 historic control patients by weekly nonstress tests and daily plasma estriols. There were 617 of 672 (91.8%) reactive nonstress tests in outpatients compared to 566 of 626 (90.4%) reactive tests in hospitalized control patients. Of 13 contraction stress tests performed in the outpatient group, only one was positive. Although 2,670 estriol determinations were done on hospitalized control patients, none was used for outpatients. No losses were attributed to unexplained antenatal stillbirth in either group. A fetal biophysical score of 8 was found to be at least as reliable as a reactive nonstress test. Antenatal surveillance in the well-controlled, insulin-requiring diabetic woman can be safely achieved with a testing sequence that consists of twice weekly nonstress tests backed up by the fetal biophysical profile and contraction stress tests.

Fifteen years of experience with antepartum fetal testing.

The introduction of antepartum fetal heart rate testing occurred in the very early 1970s. This article describes the evolution of testing within the Los Angeles County/University of Southern California Medical Center and encompasses a 15-year time period between 1971 and 1985. During this time approximately 200,000 patients were delivered of their infants. Fetal surveillance increased from less than 1% to current levels of 16% of patients. The antepartum fetal death rate was evaluated as a measure of evaluating the usefulness of antepartum testing. The fetal death rate after antepartum testing in selected high-risk patients was significantly less than that found in those patients not tested. The questions that might be raised regarding broader application of this technique and potential benefits are stated.

Screening for Down syndrome with the femur length/biparietal diameter ratio: A new twist of the data

OBJECTIVE The purpose of this study was to determine the value of discordant morphometric measurements as identifiers of Down syndrome by evaluating the relationship of biparietal diameter, femur length, biparietal diameter/femur length ratio, and cephalic index between a group of fetuses with trisomy 21 and a control population. STUDY DESIGN Biometric measurements from 48 fetuses with trisomy were reviewed and compared with 107 normal fetuses of similar gestational age. Data were analyzed in 2-week gestational age intervals to determine the effect of gestational age on ultrasonographic detection of Down syndrome. Outcome measures were subject to least-squares linear regression and the t test for analysis. RESULTS A positive relationship between abnormal morphometric measurements and fetuses with Down syndrome was detected but only during specific weeks of pregnancy. CONCLUSION Although it appears that biometric measurements may be useful for Down syndrome, further study is needed before its widespread introduction into clinical practice.