Hobbins Jc

The prevalence and biologic significance of lupus anticoagulant and antic ardiolipin antibodies in a general obstetric population

Circulating antibodies to negatively-charged phospholipids have been implicated in the genesis of adverse pregnancy outcomes. However, it has yet to be established that these antibodies are causative or that they are invariably associated with untoward perinatal outcomes. To address this issue, the prevalence of lupus anticoagulant and anticardiolipin antibodies was recorded in a low-risk obstetric population, and the outcome of untreated pregnancies were evaluated. Two of 737 patients (0.27%) had lupus anticoagulant documented by a prolonged activated partial thromboplastin time that did not correct this mixing studies. In comparison, greatly elevated concentrations of immunoglobulin M-anticardiolipin antibodies or immunoglobulin G-anticardiolipin antibodies were identified in 16/737 (2.2%) patients by means of an enzyme-linked immunosorbent assay. Spontaneous abortions occurred in both lupus anticoagulant-positive patients, suggesting that the activated partial thromboplastin time used was a relatively insensitive but specific marker for antiphospholipid antibody-associated adverse pregnancy outcomes. In contrast, although 12 of 16 anticardiolipin antibodies-positive pregnancies were complicated by perinatal loss, preterm delivery, or fetal growth retardation, four patients had uncomplicated pregnancies. Moreover, the distribution of anticardiolipin antibodies concentrations in these four patients was not clustered among the lowest anticardiolipin antibodies values, and anticardiolipin antibodies concentrations correlated weakly with adverse outcomes. These findings suggest that antiphospholipid antibodies are related to adverse pregnancy outcomes in a complex fashion and that therapy is not always required for acceptable outcomes in patients without other risk factors.

Outcome of fetal ventriculomegaly.

Ventriculomegaly was diagnosed in 50 fetuses in the perinatal ultrasound unit of Yale-New Haven Medical Center. The outcomes were elective abortion, 13 (26%); antepartum death, 0 (0%); intrapartum death, 7 (14%); neonatal death within 24 h, 11 (22%); neonatal death after 24 h and within 28 days, 3 (6%); death after 28 days, 2 (4%); survival, 14 (28%). 70% of the deaths were associated with severe congenital anomalies or intrapartum cephalocentesis. Of the 14 survivors, 6 (43%) had Bayley mental or Stanford-Binet scores of over 80, 2 (14%) had scores from 65 to 80, and 6 (43%) had scores of less than 65. The differences in outcome between this antenatal population and previously described neonatal populations with ventriculomegaly may result from the high rate (84%) of abnormalities in association with ventriculomegaly in this study and selection biases in neonatal studies.

Prenatal diagnosis of pentalogy of Cantrell.

Ten cases of prenatal diagnosis of Pentalogy of Cantrell are reported. A uniformly fatal outcome was found confirmed by a review of similar cases prenatally diagnosed by other authors. This is at variance with the data derived from the pediatric literature. Implications in obstetrical management and parental counseling are discussed.

Prenatal diagnosis of sirenomelia.

Prenatal sonographic findings of sirenomelia (or mermaid fetus) were retrospectively reviewed in eleven proven cases. Sonography showed oligohydramnios in all the cases, five (45%) of which had severe oligohydramnios that limited prenatal diagnosis by poor visibility. In five cases (45%), sirenomelia was correctly diagnosed by ultrasound; in the remainder, only bilateral renal agenesis was identified. All eleven fetuses had other associated malformations: congenital heart defects (4), skeletal deformities (10), and abdominal wall defects (4). Death resulted from termination of pregnancy in six cases and stillbirth in three cases. Two newborns died at 24 and 36 hours of neonatal life, respectively. We concluded that some cases of sirenomelia can be detected on prenatal sonograms by demonstration of a single lower extremity, oligohydramnios, and bilateral renal agenesis. Sirenomelia is a lethal condition and can be detectable in the second trimester of pregnancy, allowing for termination of pregnancy.

Fetal limb volume: a new parameter to assess fetal growth and nutrition.

Fetal growth and nutrition were evaluated using measurements of the subcutaneous tissues of the arm and leg to calculate limb volume. Arm measurements included transverse and anteroposterior arm thicknesses and subcutaneous tissue thickness; leg measurements included lengths and thicknesses of the humerus and femur, transverse and anteroposterior thigh thickness, and thigh subcutaneous tissue thickness. Volumes were calculated using equations with both circular and elliptical perimeters. Limb volume was found to be strongly correlated with gestational age, and may be a possible predictive factor of intrauterine growth retardation.

Antenatal sonographic findings of extralobar pulmonary sequestration.

Once nonimmune hydrops fetalis (NIHF) has been identified, the search for a specific cause is difficult and frequently disappointing. With recent improvements in sonographic imaging, ultrasound has become an important tool in the antenatal identification of structural abnormalities associated with hydrops fetalis. The purpose of this article is to report the association of extralobar pulmonary sequestration (EPS) and NIHF and to describe the antenatal sonographic features of a case of EPS.

Sonographic measurements of the fetal spleen: clinical implications.

Normal values for fetal spleen dimensions are proposed, including longitudinal, coronal, and transverse diameters, the perimeter, and the estimated volume. Similar values were then obtained in cases of Rh‐immunization and prolonged premature rupture of the membranes. A good correlation between amniotic fluid optical density and fetal spleen size was found. Only severely affected fetuses showed splenic values above the upper limit. Since sonographic examination can be regarded as a reliable method, nomograms can be useful in detecting growth disorders of the fetal spleen and thus provide a new complementary method to identify possible fetal diseases of genetic disorders.

A comparison of transvaginal and abdominal ultrasound in visualizing the first trimester conceptus

Ultrasound visualization of the first trimester embryo was compared using abdominal and transvaginal sonography. The parameters evaluated included the ability to obtain biometry, the ability to visualize detailed internal anatomy, and a subjective assessment of the overall image clarity. In 120 patients studied, transvaginal sonography was superior to abdominal sonography in obtaining biometric measurements in 51 cases (43%) and for visualizing internal anatomy in 45 cases (38%); also the image clarity of transvaginal sonography was subjectively better in 75 cases (63%). Vaginal sonography was superior to abdominal sonography in gestations less than or equal to 10 weeks, in obese patients, and in patients with retroverted uteri. The major difficulty encountered with transvaginal sonography was the limited maneuverability of the probe to generate specific views. Vaginal sonography can be a valuable tool in imaging the first trimester fetus, complementing, not replacing, abdominal sonography.

Rise in maternal serum α-fetoprotein concentration after chorionic villus sampling and the possibility of isoimmunization

Maternal serum alpha-fetoprotein concentrations were determined by radioimmunoassay in 72 patients immediately before and after chorionic villus sampling for prenatal diagnosis. Fifty percent showed a rise of greater than or equal to 5 ng/ml. Assuming such rises represent fetal blood crossing the intervillous space, in 14% of the cases greater than or equal to 60 microliters of fetal blood was transferred at the time of chorionic villus sampling. A positive correlation was found between the magnitude of rise in maternal serum alpha-fetoprotein levels and the amount of villi removed (r = 0.39, p less than 0.001). When cases were examined by number of passes, a greater rise in maternal serum alpha-fetoprotein levels was noted with multiple passes than with single passes for a given sample size. The transfer of greater than or equal to 60 microliters of fetal blood suggests that maternal sensitization to fetal antigens may occur after chorionic villus sampling. During biopsy, as small a sample of villi as necessary for diagnosis should be taken with as few catheter passes as possible.

How to improve your amniocentesis technique.

Physicians have become dependent upon the information provided by amniocentesis, and each year more diagnostic uses for amniotic fluid are described. Initially amniocentesis was performed without knowledge about the position of the intrauterine contents. With the advent of ultrasound, however, the operator was allowed the luxury of selecting a pocket of amniotic fluid away from fetal vital parts and the placenta. A technique is described that will enable the operator to place the amniocentesis needle into a desired area with simultaneous real-time direction.