Lars Grennert

Benefits of ultrasonic screening of a pregnant population.

Abstract. The present study describes the evolution over a 5‐year period of an ultrasonic routine screening programme of a pregnant population with participation of approximately 90 % of the pregnant women. One obvious result obtained in the screening programme is the pronounced improvement of early detection of twins, the incidence now approaching 95 % with the mean gestational age for the detection being 20 (median 19) weeks. Early detection in combination with clinical measures was associated with a decrease in the incidence of twins born preterm (before week 37) from 33 % to 10 %. The perinatal mortality rate of twins fell from 6 to 0.6 % after the introduction of this programme.

A Study of Smoking and Pregnancy with Special Reference to Fetal Growth

Abstract. A prospective study of the influence of smoking on pregnancy and its outcome was made of 5272 women in an urban community during 1974/75. Approximately 90 % of the pregnant women in the population took part in the programme. Ultrasonic measurements of the fetal biparietal diameter (BPD) were made from the 18‐20th week (early in the study the first BPD measurements were obtained at 28 weeks). Growth curves of BPD were constructed for each week, separately for the smoking groups (49 %) and the non‐smoking group (51 %) by compiling 5714 BPD measurements, only women subsequently delivered between 266 and 294 days after the last menstrual period were included to avoid erroneously skewed growth profiles. The BPD increased faster during gestation in the non‐smoking group, the difference from the smoking group being significantly apparent from the 28th week onwards and positively correlated to the average number of cigarettes smoked. There was a preponderance within the non‐smoking group for marriage, and preeclampsia; and within the smoking group for abruptio placentae, pre‐term delivery, low birth‐weight, short birth‐length, small head circumference, and small‐for‐gestational‐age. The low birth‐weights were independent of maternal prepregnant weight and weight gain. Compared with data obtained in a similar study in the same community, 1963/64, the prevalence of smoking among pregnant women had increased from 44 % to 49 %. The present study demonstrates the early onset of intrauterine growth retardation in pregnancies of smoking mothers. The results suggest that the fetal growth retardation is a direct pharmacological effect on the fetus rather than an influence resulting from nutritional deprivation and points to appearent inefficiency of the programme deterring women from smoking.

Normal Range Curves for the Intrauterine Growth of the Biparietal Diameter

Abstract. Normal range curves for the growth of the fetal biparietal diameter (BPD) measured by ultrasound were calculated in three different ways; I. 93 selected women examined longitudinally with three‐week intervals from the 16th gestational week to term. II. Measurements for each week compiled with only the first measurement from each patient. From the 20th to the 30th week, 3,243 BPD determinations obtained in a routine screening programme was used. III. 157 BPD measurements from 60 women with known date of ovulation.

Impact of betamethasone load given to pregnant women on endocrine balance of fetoplacental unit.

Corticosteroid administration to pregnant women for attempted prevention of the respiratory distress syndrome in infants (IRDS) involves the hazard of seriously altering the endocrine status in the fetoplacental unit. The effect of a betamethasone load (12 mg. daily for three days) to 19 pregnant women in the last trimester was studied, and a comparison was made with 13 control subjects. Amniocentesis was performed twice in most patients. There was a sharp reduction of cortisol in maternal serum and a significant decrease in cortisol concentration in amniotic fluid (p less than 0.05) after betamethasone treatment. Maternal urinary estriol excretion decreased; this was strongly correlated to the basal estriol excretion (r equals 0.945). A residual fraction of estriol excretion, not less than 2 mg. per 24 hour urine specimen, remained despite the high corticosteroid dose. The origin of the nondepressed part of urinary estriol might be multifactorial, e.g., nonadrenal production of estriol precursors and functional inhomogeneity of the fetal adrenal in response to adrenocorticotropic hormone stimulation. The corticosteroid treatment for prevention of IRDS transiently excludes the use of urinary estriol for assessment of fetoplacental integrity but does not influence the plasma level of human chorionic somatomammotropin.

Epidermal growth factor in maternal urine--a predictor of intrauterine growth restriction?

Epidermal growth factor (EGF), an angiogenic and mitogenic peptide, is known to be essential for normal fetal development in mice. Hypothetically, low maternal urine EGF levels might be associated with intrauterine growth restriction (IUGR) or pre-eclampsia (PE). We carried out a prospective study of 1009 consecutive women whose urine was sampled in early pregnancy (at a median of 13 weeks of gestation) between January and November 1993. Thirty women gave birth to IUGR babies and 24 developed PE. The study was designed as a nested case-control study with two matched controls for each case. EGF and human chorionic gonadotrophin (HCG) levels were measured and expressed in ng EGF/mg creatinine and IU HCG/mg creatinine. Logistic regression analysis was made with EGF or HCG levels as explanatory variables. Urinary EGF levels were significantly lower in the IUGR subgroup than in their controls, but no such difference was found between the PE subgroup and their controls. In the series as a whole, smokers were found to have lower EGF and HCG levels than non-smokers. In addition, correlation was found to exist between EGF and HCG levels (Spearmans rho 0.35; P<0.001). We conclude that a relative deficiency of EGF in early pregnancy might be one of the pathophysiological mechanisms of IUGR. However, the EGF level was an insufficiently discriminative variable to be of use for screening purposes.

ULTRASOUND AND HUMAN-PLACENTAL-LACTOGEN SCREENING FOR EARLY DETECTION OF TWIN PREGNANCIES

In the past five years gradual introduction of ultrasonic screening of pregnant women increased the ante-partum detection of multiple pregnancy from 60% in 1971 to 95% in the first half of 1975. At the same time the average gestational age for dection of multiple pregnancies diminished from thirty-three to twenty-five weeks. The corresponding figures for 1963 were 32% and thirty-six weeks. Plasma human-placental-lactogen concentrations were assessed for their value in selecting a smaller target group for subsequent ultrasonic screening. All but 2 of 39 twin pregnancies examined by single H.P.L. determinations had H.P.L. values more than 1 S.D. above the mean of the normal distribution. The use of plasma-H.P.L. screening might lower the proportion of patients requiring ultrasonography for antepartum diagnosis of multiple pregnancies to 16% of the total pregnant population.

Diagnosis of intrauterine growth retardation by serial ultrasonic cephalometry.

Abstract. The ultrasonic technique has provided a new and sensitive method for the early detection of retarded intrauterine growth (IUGR).

Towards a normalization of the outcome of twin pregnancy.

During 1973/1978, more than 90% of the pregnant women in Malmö, Sweden, were examined by ultrasound to improve the early diagnosis of twin pregnancy. This screening programme detected 90% of the twin pregnancies delivered during this period, 105 were subjected to a preventive treatment with bed rest in hospital, usually from the 29th to the 37th week (mean: 55 days). This study evaluates the outcome of these pregnancies, compared with those not treated with bed rest and with all twin pairs born a decade earlier (1963/1965). All twins of this group born up to 1 May 1977 were also monitored by regular postpartum check-ups until at least 18 months of age. Perinatal mortality was reduced to 0.5% in the group with bed rest, but remained as high (8%) as ten years earlier in the group without bed rest. The bed rest group, compared with the group without bed rest and the group of twins born 1963/1965, also showed a significantly reduced frequency of deliveries before the 37th week; also, the incidence of twins born light-for-gestational age and with birth weight below 1500 g was reduced. The incidence of twins born with cerebral palsy, mental retardation, and late development was 3% in 1973/1977 and 8.1% in 1963/1965. The reduction of mortality and morbidity of twins paralleled the improved obstetric and neonatal care. The fact that perinatal mortality and preterm delivery were reduced only among twins subjected to special antenatal supervision suggests that large gains are to be made by early detection and antenatal hospitalization. The lower CNS morbidity provides evidence of the quality improvement among the twin survivers.

Impact of Fetal and Maternal Factors on the Normal Growth of the Biparietal Diameter

Abstract. 9,846 BPD measurements made from the 20th gestational week to term were used to study the influence on the BPD growth of various maternal factors known to affect fetal size at birth. Also the covariation of the growth of BPD and fetal size at birth was studied. Cross‐sectional growth curves were constructed for each studied condition, and regressions were calculated for their difference from the normal curve. Maternal age, weight, height, and weight gain during pregnancy, and also parity were not found to affect the BPD growth; thus no difference from the normal growth curve could be found. Diseases during pregnancy, such as toxaemia, early bleeding, and infections, had no apparent effect on the BPD growth. The group of preterm delivered infants had a slow intrauterine growth rate from the 26th week. Throughout pregnancy, male infants had mean BPD values 1.7 % larger than female infants. The intrauterine growth pattern reflected fetal size at birth. The large fetuses (heavy, fat, and tall) had a faster growth rate from the 20th week on, and the regression lines on the difference from the normal mean pointed to a starting point of the deviation close to zero weeks. The short infants mirrored the tall infants; but for the negative weight variants (thin and light), the deviation from the normal mean increased towards term. Placental weight in relation to infant weight was of no significance for the intrauterine BPD growth.

Routine Hospital Care Does Not Improve Prognosis in Twin Gestation

The effects of routine hospital care in twin gestation were evaluated by comparing the gestational outcome in two neighbouring university departments in southern Sweden. In Malmö, 79% (175/223) of all women with a twin pregnancy were given routine hospital care between the 26‐28th and 35th gestational week, whereas in Lund only 4% (16/409) received such treatment. Hospitalization averaged 9 weeks in Malmö, versus 2 weeks in Lund. We found no significant differences between the two areas regarding gestational length, birth weight, or perinatal mortality. This study indicates that routine hospital care does not improve the prognosis in twin gestation.