Heléne Edvall

Spontaneous cephalic version of breech presentation in the last trimester

Summary. A prospective longitudinal investigation of spontaneous cephalic version from breech presentation in the last trimester is reported. All pregnancies were assessed with ultrasound in the 32nd week of gestation, and were thereafter checked weekly. Of the 310 singleton breech presentations identified at 32 weeks, spontaneous cephalic version occurred in 177 (57%) while breech presentation persisted in 133 patients (43%). Of 140 patients with a breech presentation at delivery 95% were already presenting by the breech in the 32nd week. Spontaneous cephalic version was less likely in pregnancies with extended fetal legs, low birth‐weight, short umbilical cord and primiparity.

First-trimester diagnosis on chorionic villi obtained by direct vision technique

SummaryAn improved technique for direct vision chrionic biopsy that gives a clear view of the amniotic sac was developed. With this technique, used in 48 women prior to vacuum aspiration and in six cases for diagnosis (karyotyping or enzyme analysis), it was possible to obtain chorionic villi free from contamination by maternal tissue. It was also possible to pick out villi (rich in blood vessels and with abundant buds on their surface) found to be most capable of growing in vitro. In the diagnostic cases, the pregnancies have continued uneventfully since the sampling; one pregnancy is now in the 32nd week.

First‐Trimester Diagnosis of Cystic Nuchal Hygroma

During ultrasound scanning while sampling chorionic villi in the 12th week of gestation, a cystic area was unexpectingly detected in the region of the fetal neck, that turned out to be a cystic nuchal hygroma associated with hydronephrosis. Ultrasonic findings of fetal anomaly at this early stage have not been reported previously, as far as we know. The woman, 43 years of age, had had two healthy children by her previous husband. Her present husband, 41 years old, had no children of his own. She attended the clinic in the 12th gestational week for chorionic villi sampling (having been delayed by the intervening Christmas and New Year holidays), her age being the indication for villi sampling. Ultrasound examination during the procedure revealed the presence of a symmetrical, smooth-walled, echo-free, cystic structure in the nuchal region (Figs. 1 and 2). The cranial vault appeared to be completely formed.

Chromosome analysis in 100 cases of first trimester trophoblast sampling

The cytogenetic findings in 20 experimental and 80 diagnostic cases of first trimester trophoblast biopsy are presented. All samples were obtained between the 8th and 13th week of gestation with the direct vision, trans‐cervical technique. Except when fetal sexing because of X‐linked disease was the issue, long‐term culture with in situ preparation was the method routinely employed in processing the biopsies for cytogenetic analysis. In 78 of the 80 clinical cases and in all reported experimental cases we were successful in establishing a karyotype from the sampled tissue. Unbalanced karyotypes were found in two experimental and six clinical cases. Tetraploidy was found in one clinical case, but was not confirmed in subsequently sampled amniotic fluid cells. In another clinical case, we were unable to confirm in the aborted placenta the trisomy 18 found in the trophoblast biopsy. In the rest of the induced abortions in the clinical series, the karyotype arrived at prenatally has been confirmed, and the 27 babies so far born have been healthy and with phenotypic sex corresponding to the prenatal findings. Six women have miscarried after sampling; in one of these cases the fetus had the karyotype 47,XX,+ 13.

TROPHOBLAST SAMPLES SUITABLE FOR LONG-TERM CULTURE

Abstract. Chorionic villi were obtained by a direct vision technique. Villi without vessels (38 cases) failed to grow in vitro, irrespective of the amount of tissue. Vascular villi with an estimated weight exceeding 5 mg (71 cases) grew in vitro—with two exceptions.

Removal of Iud:s in Early Pregnancy

About half of all pregnancies occurring with an intrauterine device (IUD) in situ terminate spontaneously in the first or second trimester (1). Such abortions may be accompanied by infection and even sepsis (2). If the IUD is expelled or removed, the incidence of spontaneous fetal loss is reduced to about 20%. Moreover, the chance of a live birth being premature is about four times as great when the IUD remains in situ as when it is extracted (1). The general rule is to remove the IUD where a pregnancy is to proceed. There is an even chance, however, that the threads have been drawn up into the uterus. In such cases, Wagner et al. (3) were able to remove the IUD under hysteroscopic vision by using C 0 2 to distend the uterine cavity. The removal was successful in 14 out of 18 cases; in the remaining 4, the amniotic sac was damaged and the uterus had to be evacuated. This technique has not been adopted as general practice, possibly because the effect on the fetus of the COz gas insufflated into the uterine cavity is unknown; another reason may be the technical difficulties that arise when bleeding impairs vision during attempts to remove an embedded IUD. We should like to present another hysteroscopic technique for removing an IUD in early pregnancy without such disadvantages. The technique involves the distension of the uterine cavity with saline solution, a procedure similar to that we have used in diagnostic cases of chorionic villi sampling in the first trimester (4). Our present series comprised seven women scheduled for pregnancy termination by vacuum aspiration in the 8th to 10th week of pregnancy, each of whom had an IUD in situ with its threads retracted. In one case (Fig. l) , the IUD was found to be attached to the upper part of the amniotic sac with one of the two transverse arms embedded in the decidua covering the sac, whilst the vertical arm pointed towards the fundus uteri. Under direct vision, the free transverse arm was grasped by the forceps jaws and the embedded arm gently withdrawn from the decidua. The IUD was then reversed, the threads grasped and the IUD removed. In another case, the vertical arm was embedded in the uterine wall perpendicular to its surface. Copious bleeding occurred during the extraction, but due to the rinsing effect of the saline, removal was nevertheless achieved under direct vision and without damaging the amniotic sac. The bleeding stopped shortly after the extraction had been completed. In the remaining five cases, the IUD was lying free in the extra-amniotic space and was easily removed. The outcome of pregnancy following the use of saline to distend the uterus for hysteroscopy may be exemplified by our results with chorionic villi sampling for diagnostic purposes, where the same disten-

Direct-vision sampling of chorionic villi during extra-amniotic instillation of physiologic saline solution: Effect on intrauterine pressure and fetal heart activity☆

After 150 ml of physiologic saline solution had been infused into the extra-amniotic space before first-trimester vacuum aspiration abortion, intrauterine pressure ranged between 16 and 23 mm Hg, thus not more than during Braxton Hicks contractions. At chorionic villi sampling during continuous saline solution infusion, fetal heart activity (beats per 15 seconds) decreased temporarily from about 36 to about 33.