Jose Nores

Amniotic fluid white blood cell count: A rapid and simple test to diagnose microbial invasion of the amniotic cavity and predict preterm delivery

The purpose of this study was to determine the value of amniotic fluid white blood cell count in the diagnosis of microbial invasion of the amniotic cavity. Amniotic fluid was retrieved by amniocentesis from 195 patients with preterm labor and intact membranes. Fluid was cultured for aerobic and anaerobic bacteria, as well as for mycoplasmas. The prevalence of a positive amniotic fluid culture was 12.8% (25/195). Patients with a positive amniotic fluid culture had a significantly higher median amniotic fluid white blood cell count than did patients with a negative amniotic fluid culture (median, 6 cells/mm3; range, 0 to 11,000 cells/mm3 vs median, 320 cells/mm3; range, 1 to 4480 cells/mm3; p less than 0.0001). An amniotic fluid white blood cell count greater than or equal to 50 cells/mm3 had a sensitivity of 80% (20/25), a specificity of 87.64% (149/170), a positive predictive value of 48.78% (20/41), and a negative predictive value of 96.75% (149/154) in the detection of a positive amniotic fluid culture for microorganisms. Although the sensitivity of an amniotic fluid white blood cell count (greater than or equal to 50 cells/mm3) in the detection of microbial invasion of the amniotic cavity was greater than that of the Gram stain of amniotic fluid (80% [20/25] vs 48% [12/25]; p less than 0.05), the specificity was lower (87.64% [149/170] vs 98.8% [168/170]; p less than 0.05). However, 88% (15/17) of all patients with an amniotic fluid white blood cell count greater than or equal to 50 cells/mm3 and a negative amniotic fluid culture had a spontaneous preterm delivery. We conclude that the amniotic fluid white blood cell count is a sensitive, simple, and inexpensive test for the detection of microbial invasion of the amniotic cavity. An elevated amniotic fluid white blood cell count is a risk factor for preterm delivery.

Amniotic fluid glucose concentration: A rapid and simple method for the detection of intraamniotic infection in preterm labor

The purpose of this study was to determine whether amniotic fluid glucose concentrations is of value in the rapid diagnosis of intraamniotic infection. Amniocenteses were performed in 168 patients with preterm labor and intact membranes. Amniotic fluid was cultured for aerobic and anaerobic bacteria, as well as Mycoplasma species. The prevalence of positive amniotic fluid cultures was 13.6% (23/168). Patients with positive amniotic fluid cultures for microorganisms had significantly lower median amniotic fluid glucose concentrations than patients with negative amniotic fluid cultures (median 11 mg/dl, range 2 to 30 mg/dl vs median 28 mg/dl, range 3 to 74, respectively; p less than 0.001). Amniotic fluid glucose concentrations below 14 mg/dl had a sensitivity of 86.9% (20/23), a specificity of 91.7% (133/145), a positive predictive value of 62.5% (20/32), and a negative predictive value of 97.8% (133/136) in the detection of a positive amniotic fluid culture. Amniotic fluid glucose determination is a rapid, sensitive, inexpensive, and simple test for the detection of intraamniotic infection in women with preterm labor and intact membranes.

MECONIUM-STAINED AMNIOTIC FLUID : A RISK FACTOR FOR MICROBIAL INVASION OF THE AMNIOTIC CAVITY

The purpose of this study was to determine whether meconium-stained amniotic fluid is a marker for microbial invasion of the amniotic cavity. Amniocentesis was performed on 707 patients presenting with preterm labor and intact membranes. Meconium-stained amniotic fluid was present in 4.2% (30/707) of patients with preterm labor. The prevalence of positive amniotic fluid cultures was significantly higher in women with meconium-stained amniotic fluid than in women with clear fluid (33% [10/30] vs 11% [75/677]; p = 0.001; odds ratio = 4.01; 95% confidence interval = 1.6 to 9.4). Patients with meconium-stained amniotic fluid were also more likely to have failed tocolysis and delivered a preterm neonate more frequently than patients with clear fluid (83% [25/30] vs 38% (258/677); p = 0.0001; odds ratio = 8.1; 95% confidence interval = 2.9 to 24.4). We conclude that meconium-stained amniotic fluid is a risk factor for microbial invasion of the amniotic cavity and preterm delivery in women with preterm labor and intact membranes.

Infection and labor: VI. Prevalence, microbiology, and clinical significance of intraamniotic infection in twin gestations with preterm labor

The purpose of this study was to establish the prevalence, microbiology, and outcome of microbial invasion of the amniotic cavity in twin gestation presenting with preterm labor and intact membranes. Amniocenteses were performed on both sacs of 46 women with twin gestations, preterm labor, and intact membranes. Indigo carmine was injected to ensure sampling of both amniotic sacs. Amniotic fluid was cultured for aerobic and anaerobic bacteria, Mycoplasma hominis, and Ureaplasma urealyticum. A positive amniotic fluid culture of at least one sac was noted in 10.8% (5/46) of patients admitted in preterm labor and in 11.9% (5/42) of women delivered of preterm neonates. Of the five patients with microbial invasion of the amniotic cavity, three had microorganisms isolated from both sacs. The presenting sac was involved in all cases, supporting an ascending route for microbial invasion of the amniotic cavity in twin gestation. Polymicrobial infection was found in three of the eight amniotic sacs with positive cultures. In two cases different organisms were isolated from each sac. All patients with positive amniotic fluid cultures were delivered of preterm infants within 48 hours of amniocentesis. Patients with positive amniotic fluid cultures presented with preterm labor at an earlier gestational age and with more advanced cervical dilatation than did women with negative amniotic fluid cultures. Clinical evidence of chorioamnionitis subsequently developed in two of five women with positive amniotic fluid cultures. The interval between amniocentesis and delivery was shorter in women with positive amniotic fluid cultures than in women with negative amniotic fluid cultures (median: 3.5 vs 168 hours, p less than 0.0001). Infants born to women with microbial invasion of the amniotic cavity had a lower median birth weight and a higher incidence of respiratory distress syndrome than those born to women with negative amniotic fluid cultures (birth weight: 1085 vs 1975 gm, p = 0.024; respiratory distress syndrome: 37.5% vs 8.3%, p = 0.04).

Preterm delivery: A risk factor for retained placenta

The purpose of this study was to determine whether preterm delivery, with and without intraamniotic infection, is a risk factor for retained placenta. This complication occurred more frequently in women with preterm vaginal delivery than in women with term vaginal delivery (9.1% [21/231] vs 1.1% [6/561]; p less than 0.00001; odds ratio = 9.25). There was no significant difference in the prevalence of retained placenta between women with preterm labor and intact membranes and those with preterm premature rupture of membranes (8% [10/125] vs 10.4% [11/106]; p greater than or equal to 0.05). A positive amniotic fluid culture or clinical chorioamnionitis was not associated with a higher incidence of retained placenta. This study indicates that preterm delivery is associated with an increased risk of complications of the third stage of labor.

Eradication of Ureaplasma urealyticum from the amniotic fluidwith transplacental antibiotic treatment

Ureaplasma urealyticum was isolated from the amniotic fluid of a patient with preterm premature rupture of membranes at 24 weeks. A second amniocentesis performed 48 hours later indicated an increase in the number of neutrophils in the amniotic fluid. Treatment with erythromycin, ampicillin, gentamicin, and clindamycin was instituted for a period of 6 days. Amniotic fluid analysis from a third amniocentesis performed 24 hours after discontinuation of antibiotic treatment revealed only a few white blood cells and was negative for microorganisms. The pregnancy continued for 22 days after admission, at which time spontaneous labor began. The neonate survived with no sequelae and had negative blood cultures. Antibiotic treatment was associated with eradication of Ureaplasma urealyticum from the amniotic cavity, pregnancy prolongation, and neonatal survival.

Antenatal Therapy of Smith-Lemli-Opitz Syndrome

Objectives: Smith-Lemli-Opitz syndrome (SLOS) is a recessively inherited disorder caused by an inborn error of cholesterol metabolism that results in deficiency of cholesterol and accumulation of the cholesterol precursor, 7-dehydrocholesterol (DHC) and its epimer, 8-DHC. Affected patients present with congenital anomalies, growth restriction, and mental retardation. Postnatal treatment with cholesterol supplementation has been shown to improve plasma sterol levels and has resulted in improved growth and development in many patients. We hypothesized that prenatal supplementation of cholesterol could potentially arrest some of the adverse consequences of cholesterol deficiency at an earlier stage of development. Methods: SLOS was diagnosed in the third trimester in a fetus initially identified by sonography with intrauterine growth restriction and ambiguous genitalia and confirmed by elevated levels of 7- and 8-DHC in amniotic fluid. Antenatal supplementation of cholesterol was provided by fetal intravenous and intraperitoneal transfusions of fresh frozen plasma (cholesterol level = 219 mg/dl). Results: The in utero transfusions resulted in increased levels of fetal cholesterol, as measured in blood samples obtained by cordocentesis. In addition, fetal red cell mean corpuscular volume rose, which further indicated that the exogenous cholesterol was incorporated into the fetal erythrocytes. Conclusions: Antenatal treatment of SLOS by cholesterol supplementation is feasible and results in improvement in fetal plasma cholesterol levels and fetal red cell volume. SLOS may be added to the growing list of human genetic disorders for which prenatal diagnosis is available and therapeutic intervention may be possible.

In utero diagnosis and management of fetal subdural hematoma

The in utero ultrasonographic diagnosis of a fetal subdural hematoma is presented. The value of percutaneous umbilical blood sampling, transvaginal ultrasonography, and magnetic resonance imaging for diagnosis and management is discussed.

Validation of fetal telemedicine as a new obstetric imaging technique

OBJECTIVE Our purpose was to establish whether obstetric ultrasonography interpreted by a live video telemedicine link is comparable to interpretation by videotape review in a low-risk patient population. STUDY DESIGN An Integrated Services Digital Network (ISDN 6) was established from three satellite offices to our central prenatal diagnostic center. Patients seen at these satellite offices had a complete fetal anatomic survey recorded onto videotape by a trained ultrasonographer. A live interactive video telemedicine link was then established to our center by the digital network, and a perinatologist directed the ultrasonographer through the anatomy survey. Subsequently a different perinatologist, blinded to the telemedicine interpretation, reviewed the videotaped examination. The reports from the videotaped and telemedicine scans were then compared on the basis of a score of 33 anatomic items. RESULTS The first 200 patients seen at the satellite offices were included. Telemedicine and videotape interpretations provided similar scores in 84% of scans. In 17 of the 33 anatomic categories telemedicine provided significantly better scores than videotape, whereas in the remaining 16 anatomic categories the scores were equivalent. More videotape than telemedicine examinations required repeat ultrasonography because of suboptimal imaging (10% vs 3%, p = 0.003). CONCLUSIONS The interpretation of obstetric ultrasonography with use of live video telemedicine is comparable to videotape review. Fetal telemedicine may prove to be a useful tool for providing ultrasonographic interpretation of fetal anatomy to a network of low-risk obstetric practices.

Bilateral choroid plexus cysts in trisomy 21

Whether karyotyping is indicated in a fetus with choroid plexus cysts who is otherwise structurally normal is still controversial. Many authors have suggested basing the decision on cyst size, bilaterality, persistence with advancing gestational age, and association with other anomalies. We report a case of large bilateral choroid plexus cysts in a fetus with trisomy 21 who had no evidence of congenital anomalies or ultrasonographic signs of Down syndrome. Cyst sizes diminished by half over a 3-week period of follow-up. It appears that diminishing size alone should not be considered sufficient reassurance about the normality of the fetal karyotype. A similar case has been previously reported, and it is conceivable that choroid plexus cysts are associated not only with trisomy 18 but also with trisomy 21.