Charles Ingardia

The Fetal Biophysical Profile and Its Predictive Value

Six fetal biophysical variables--the nonstress test, fetal movements, fetal breathing movements, fetal tone, amniotic fluid volume, and placental grading (biophysical profile)--were assessed in 150 high-risk pregnancies during a 30-minute observation period. The predictive value of the nonstress test alone, biophysical scoring, and contraction stress test alone in the identification of the healthy fetus as well as the fetus in jeopardy are discussed. The relationships between individual variables and combinations of variables to the outcome of pregnancy, as reflected by abnormal intrapartum fetal heart rate patterns, meconium during labor, fetal distress, and perinatal mortality rate were determined. The biophysical profile of all hypoxic fetuses was analyzed. These data suggest that the biophysical profile is more accurate in the identification of the hypoxic fetus than any other single method; therefore, a new protocol including the biophysical profile for antepartum fetal evaluation is presented.

Obesity-related complications of pregnancy vary by race.

OBJECTIVE To evaluate racial effects on obstetric complications in obese gravidas. METHODS The obstetric database was reviewed for the period 6/1/94 to 3/31/97. All clinic patients delivering singletons were included. Obesity was defined as a body mass index (BMI) of 29 kg/m2 or more, or a pre-pregnancy weight of 200 pounds or more. Complications studied included hypertension, diabetes, cesarean delivery, and fetal macrosomia. RESULTS Of 2,424 eligible subjects, 168 were obese (6.9%). Obese patients had higher rates of chronic hypertension and pregestational diabetes, as well as increased rates of preeclampsia, gestational diabetes, fetal macrosomia, cesarean delivery, and operative vaginal delivery compared to nonobese patients. Of the obese patients, 105 (63%) were Hispanic, 39 (23%) were African American, and 24 (14%) were White; no Asian or Mixed/Other patients were obese. Mean BMIs of the obese subgroups did not differ (P = 0.14), but prepregnancy weights were greater in Whites than Hispanics (P < 0.002). Obese Hispanics had an increased rate of gestational diabetes (P = 0.04) and of infant weight > or =4,500 g (P =.03). Obese Hispanic and African American women were more likely than obese Whites to deliver by cesarean (P = 0.03). CONCLUSION Racial differences affect the complication rates in obese gravidas, and may influence prenatal counseling and pregnancy management.

Management of multiple gestation.

The following perinatal intensive care management protocol is suggested to minimize morbidity and mortality in multiple pregnancy. 1. Early diagnosis is essential, with ultrasound examination regarding as invaluable for all pregnant patients. If ultrasound examination has not been done, multiple pregnancy should be suspected in all patients who have a family history of dizygotic births, are large for dates or anemic, or have a low-grade preeclampsia. 2. Maternal care should be provided at a tertiary care (level III) perinatatl center, which is more fully equipped to manage multiple gestation. 3. Bed rest, if instituted early enough (26-29 weeks) appears to be of value, especially in promoting increased birth weight. 4. A liberal approach to performing cesarean birth is suggested when any abnormal presentation exists. 5. Aggressive management, using tocolytic agents to delay premature labor and steroids to accelerate pulmonary maturity, should be strongly considered. 6. The personnel of a neonatal intensive care unit should employ a team approach to the preparation for and management of multiple preterm births.

Prenatal Sonographic Diagnosis of Hemivertebrae Associations and Outcomes

Objective. The purpose of this study was to evaluate associated anomalies and outcomes of fetuses with prenatally diagnosed hemivertebrae. Methods. Fetuses with prenatally diagnosed hemivertebrae, excluding those associated with spina bifida, were identified by searching the prospectively maintained ultrasound databases of 4 institutions from 1997 to August 2007. Associated birth defects were tabulated by organ system and hemivertebra location. Outcomes included karyotypes, gestational ages, and routes and outcomes of deliveries. Results. Nineteen fetuses had a diagnosis of hemivertebrae at a mean gestational age ± SD of 20.5 ± 5.4 weeks. Fourteen (73.7%) fetuses had additional anomalies, of which 5 (35.7%) were syndromic (4 with cloacal exstrophy and omphaloceles and 1 with Jarcho‐Levin syndrome). Karyotypes were normal in all 11 available cases, each of which had additional anomalies. Fourteen (73.7%) neonates were live born at a mean gestational age of 34.9 ± 4.3 weeks, of which 7 (50%) were born by cesarean delivery. Ten neonates (71.4%) were delivered before term, and 4 (28.6%) were growth restricted (<10th percentile). Two (14.3%) of these neonates died; both had cloacal exstrophy and large omphaloceles. The remaining pregnancies were terminated (4 [21.1%]) or had a fetal death (1 [5.3%]). Conclusions. Most fetuses with prenatally diagnosed hemivertebrae have additional anomalies, often syndromic, which affect the prognosis. Affected pregnancies have high rates of cesarean delivery and growth restriction. Neonates with nonisolated hemivertebrae are more often delivered before term and have higher mortality rates.

Prenatally Diagnosed Sacrococcygeal Teratoma: A Unique Expression of Trisomy 1q

Partial duplication of the long arm of chromosome 1 has been observed in fetal intracranial teratomas. We sonographically diagnosed a 19-week fetus with sacrococcygeal teratoma, cerebral ventriculomegaly, and cerebellar hypoplasia. Chromosomal analysis of amniocytes showed an unbalanced translocation between chromosomes 1 and 15, resulting in trisomy 1q21-->1 qter. Duplication or over expression at more than one locus on the long arm of chromosome 1 may be required for the development of an extra-gonadal teratoma.

Fetal intracardiac echogenic foci: current understanding and clinical significance.

The detection of fetal intracardiac echogenic foci (ICEF) by ultrasound was first reported in 1987. Despite many investigations, the relationship of ICEF with congenital heart malformations and chromosomal abnormalities remains unclear. This review describes the current understanding of ICEF based on a literature search from 1980 to the present. ICEF are observed in 0.5 to 20 percent of fetuses, with an overall frequency of 5.6 percent. These small, discrete structures near the papillary muscles and chordae tendinae move in synchrony with the intraventricular valves. They likely represent microcalcification of the papillary muscles. ICEF are most commonly seen in the left ventricle and occasionally in the right ventricle or bilaterally. Intra-atrial or diffuse ICEF are rare. In the chromosomally normal fetus, ICEF are not associated with congenital heart defects. The presence of ICEF in fetuses at high risk for chromosomal abnormalities suggests an increased possibility of aneuploidy, especially if other sonographic markers are noted. A similar association is observed with trisomy 21 in particular. The significance of ICEF in fetuses at low risk for aneuploidy is less clear and represents an area for future research.

INTENTIONAL IRON OVERDOSE IN PREGNANCY—MANAGEMENT AND OUTCOME

The objectives of our study were to 1) determine if peak maternal serum iron level or toxicity stage after intentional overdose is associated with adverse maternal-fetal outcome, and 2) describe the use of deferoxamine antidote therapy in obstetric patients. A computer search of the English language literature from 1966-1998 used the key words iron toxicity, iron poisoning, deferoxamine, and pregnancy to identify peer-reviewed papers reporting intentional iron overdoses in pregnancy. Two investigators independently extracted data from articles and their references including stage of toxicity (0 = asymptomatic, 1 = gastrointestinal symptoms, 2 = metabolic disturbance, 3 = organ failure), with differences resolved by consensus. Statistical analysis used the Student t-test, Fisher exact test, or ANOVA, as appropriate. Fourteen publications were identified, describing 61 cases of obstetric iron overdose, including one recent case at our institution. Compared with women who had lower peak levels, women with peak serum iron levels > or =400 mcg/dL were more frequently symptomatic (12/13 vs. 5/10, respectively, p = 0.05). Peak iron level > or =400 mcg/dL was not associated with increased risk of spontaneous abortion, preterm delivery, congenital anomalies, or maternal death. However, patients with stage 3 toxicity were more likely to spontaneously abort (1/3 vs. 1/56, respectively), deliver preterm (2/3 vs. 6/56, respectively), or experience maternal death (3/3 vs. 0/56, respectively). The proportions of patients treated with deferoxamine and total dosages of deferoxamine were similar by peak iron level (> or =400 vs. <400 mcg/dL) and toxicity stage (0-3). Peak iron levels > or =400 mcg/dL are associated with symptomatic iron overdose. Stage 3 toxicity is associated with spontaneous abortion, preterm delivery, and maternal death.

The effect of betamethasone on neonatal neutrophil chemotaxis.

ABSTRACT. Antenatal maternal glucocorticoid administration has been widely used to accelerate fetal lung maturation. Glucocorticoids have also been used postnatally selected neonates as antiinflammatory agents. Numerous studies have shown that glucocorticoids inhibit multiple components of the immune system including neutrophil (PMN) function in children and adults. Since PMNs are of critical importance in host defense against bacterial infection, impaired PMN function in newborn infants is thought to be an important cause of their increased morbidity and mortality from bacterial infection. Further compromise of neonatal PMN function by exogenous factors such as glucocorticoids may therefore be of significant clinical importance. A micropore filter chemotactic assay used to determine the in vitro effect of betamethasone on the random migration and directed migration (chemotaxis) of PMNs from 18 neonates. The addition of a concentration of betamethasone (0.01 μg/ml) similar to that found in cord blood following a standard dose administered to the mother resulted in a significant (p < 0.01) inhibition in mean neonatal PMN random migration (–15.0 ± 0.8%) and chemotaxis (–23.5 ± 3.0%). A similar inhibition was not found when PMNs from 14 adults were exposed to the same concentrations of betamethasone. Betamethasone administration to pregnant women or their newborn infants may further impair PMN motility to an increased morbidity and mortality from bacterial infection in neonates.

Unexplained elevated midtrimester maternal serum levels of alpha fetoprotein, human chorionic gonadotropin, or low unconjugated estriol: Recurrence risk and association with adverse perinatal outcome

OBJECTIVE To determine if women experiencing an unexplained elevated maternal serum alpha fetoprotein (MSAFP; > or =2.0 MoM) or human chorionic gonadotropin (hCG; > or =2.0 MoM), or low unconjugated estriol (E3; < or =0.5 MoM) in one pregnancy are at increased risk for similar results in a subsequent pregnancy, and to determine if recurrence of these analyte extremes is associated with adverse perinatal outcome. METHODS We identified all women delivering two consecutive singleton pregnancies at one hospital between 1992-1997 for whom second trimester trisomy 21 serum screen was performed in each pregnancy. All screens were performed in a single laboratory. Each pregnancy delivered after 20 weeks and had gestational age confirmed by ultrasound prior to 24 weeks. Subjects were excluded if a fetal anomaly or aneuploidy was present. Adverse outcomes included abruption, oligohydramnios, preeclampsia, preterm membrane rupture, preterm delivery, stillbirth, birthweight <10th centile, and admission to neonatal intensive care unit (NICU). RESULTS A total of 538 women had 1,076 pregnancies meeting inclusion criteria; 12/515 (2.3%) of women with a normal MSAFP, 28/470 (6.0%) with a normal hCG, and 11/504 (2.2%) with a normal E3 in the first pregnancy had an anomalous result for the respective analyte in the second pregnancy. In contrast, only 4/23 (17.4%) patients with an elevated MSAFP (P = 0.003), 14/44 (31.8%) with an elevated hCG (P < 0.001), and 2/10 (20.0%) with a low E3 (P < 0.025) in the first pregnancy had the same analyte anomaly recur in the second pregnancy. The odds ratios for recurrent elevated MSAFP, hCG, and low E3 were 7.5, 5.3, and 9.2, respectively. Adverse perinatal outcomes occurred with similar frequency, regardless of MSAFP, hCG, or E3 results in consecutive pregnancies, using women with normal MSAFP, hCG, and E3 results in one or both pregnancies as controls. CONCLUSIONS Women experiencing an anomalous serum analyte in one pregnancy are at significant risk to experience the same analyte result in a subsequent pregnancy.

Increased neonatal morbidity despite pulmonary maturity for deliveries occurring before 39 weeks

Objective: To compare neonatal outcomes following deliveries <39 weeks after confirmation of fetal lung maturity with scheduled deliveries ≥39 weeks. Methods: A retrospective cohort study examining neonatal outcomes of women who were delivered following documented fetal pulmonary maturity at 36, 37, and 38 weeks compared to women undergoing a scheduled delivery at 39, 40, and 41 weeks. The χ2-test and Student’s t-test were used to compare categorical and continuous data, respectively. Results: Delivery prior to 39 weeks following fetal pulmonary maturity was associated with a 8.4% composite neonatal morbidity rate as compared to 3.3% for deliveries at 39 weeks or greater (relative risk [RR] 2.9; confidence interval [CI] 2.4–3.6). Neonatal respiratory morbidity was significantly higher (5.4%) for those delivering at less than 39 weeks with documented fetal pulmonary maturity as compared to 2.1% for those delivering at 39 weeks or greater (RR 3.0; CI 2.3–3.9). Increased neonatal morbidity persisted for those delivered prior to 39 weeks even after excluding all diabetics (p < 0.001). Significant increases in neonatal morbidity were noted for deliveries prior to 39 weeks regardless of the mode of delivery. Conclusion: Despite fetal pulmonary maturity, delivery before 39 weeks is associated with significantly increased neonatal morbidity when compared to scheduled deliveries at 39 weeks or greater.