Maria de Lourdes Brizot

Cervical length at 11–14 weeks' and 22–24 weeks' gestation evaluated by transvaginal sonography, and gestational age at delivery

To compare cervical length measurements obtained at 11 to 14 weeks and 22 to 24 weeks of gestation in an unselected group of pregnant women and to correlate the measurements with time of delivery.

Prediction of preterm delivery in the second trimester.

OBJECTIVE: The aim of this study was to estimate the probability of spontaneous delivery at 34 weeks or less according to cervical assessment by transvaginal scan associated with previous obstetric history. METHODS: Ultrasound transvaginal cervical length and presence of funneling were evaluated in 1,958 singleton pregnancies between 21 and 24 weeks of gestation. For the prediction of preterm delivery, the results of cervical assessment were analyzed in association with the previous obstetric history of preterm delivery, spontaneous miscarriage, and curettage. Sensitivity, specificity, and positive and negative predictive values for the various cutoff cervical lengths in the groups with or without previous history of preterm delivery were calculated. Multivariable regression analysis was used to identify the predictive factors for preterm delivery at 34 weeks or less. RESULTS: The incidence of spontaneous delivery at gestational age of 34 weeks or less was 3.4%. The mean cervical length was 30.1 mm (standard deviation 10.1 mm) in the group with previous history of prematurity (n = 180) and 35.8 mm (standard deviation 7.9 mm) in the group without previous history of prematurity (P < .001). The mean cervical length in the group of patients who delivered at or before 34 weeks was 23.8 mm, and for patients who delivered after 34 weeks it was 35.6 mm (P < .001). The mean gestational age at delivery was significantly lower in the group with funneling compared with the group without funneling (33.5 weeks versus 38.8 weeks, P < .001). Logistic regression analysis demonstrated that cervical length, funneling, and history of previous preterm delivery were independent contributors for preterm delivery. CONCLUSION: Ultrasound cervical assessment may be useful in the prediction of preterm delivery, but it should also be considered in association with the obstetric history of prematurity. LEVEL OF EVIDENCE: II-2

Early neonatal morbidity and mortality in growth-discordant twins.

Objective. To evaluate early neonatal morbidity and mortality in twin pregnancies with growth discordance. Design. Retrospective study. Setting. Tertiary teaching hospital, Sao Paulo, Brazil. Population. A total of 151 twin pregnancies managed and delivered at the Multiple Pregnancy Unit at São Paulo University Hospital between 1998 and 2004. Methods. Comparison between twin pregnancies with weight discordance ≥20% and pregnancies concordant for fetal weight. Cases with fetal death, abnormalities, twin‐to‐twin transfusion and delivery before 26 weeks or in another hospital were excluded. Outcome measures. Early neonatal morbidity (Apgar at 5 minutes <7, respiratory or neurological complications, infection, necrotizing enterocolitis, length of hospital stay) and mortality. Results. Forty (26.5%) pregnancies presented discordance ≥20% and 111 (73.5%) were concordant. In the discordant group, 75% of pregnancies had at least one growth restricted fetus (<10th centile). In concordant twin pregnancies, monochorionic cases (22.5%) presented with lower gestational age (34.3 vs. 36.2 weeks), lower birthweight (2,067 vs. 2,334 g) and a longer period of hospital stay (5.5 vs. 3.0) compared to dichorionic concordant twins. No differences between monochorionic and dichorionic subgroups were observed in discordant twins. Pregnancies in which at least one baby was born with a birthweight below the 10th centile showed that discordant pregnancies had a lower gestational age at delivery (35.2 vs. 36.8 weeks) and a longer period of hospital stay (9 vs. 4 weeks) compared to concordant cases. Neonatal mortality was similar in discordant (3.7%) and concordant (4.5%) twins. Conclusion. Early perinatal morbidity is increased in twin pregnancies with birthweight discordance ≥20% only when associated with fetal growth restriction and low birthweight.

Feelings of women regarding end-of-life decision making after ultrasound diagnosis of a lethal fetal malformation

OBJECTIVE this study investigated the feelings of women regarding end-of-life decision making after ultrasound diagnosis of a lethal fetal malformation. The aim of this study was to present the decision making process of women that chose for pregnancy termination and to present selected speeches of women about their feelings. DESIGN open psychological interviews conducted by a psychologist immediately after the diagnosis of fetal malformation by ultrasound. Analysis of the results was performed through a content analysis technique. SETTING the study was carried out at a public university hospital in Brazil. PARTICIPANTS 249 pregnant women who had received the diagnosis of a severe lethal fetal malformation. FINDINGS fetal anencephaly was the most frequent anomaly detected in 135 cases (54.3%). Termination of pregnancy was decided by 172 (69.1%) patients and legally authorised by the judiciary (66%). The reason for asking for termination was to reduce suffering in all of them. In the 77 women who chose not to terminate pregnancy (30.9%), the reasons were related to feelings of guilt (74%). KEY CONCLUSIONS the results support the importance of psychological counselling for couples when lethal fetal malformation is diagnosed. The act of reviewing moral and cultural values and elements of the unconscious provides assurance in the decision-making process and mitigates the risk of emotional trauma and guilt that can continue long after the pregnancy is terminated.

Bowel dilation as a predictor of adverse outcome in isolated fetal gastroschisis.

This study was designed to evaluate bowel diameter as a predictor of adverse outcome in isolated fetal gastroschisis.

Reference range for cervical length in twin pregnancies

Background.  Twin pregnancies are at increased risk of preterm delivery, and cervical length measurement by transvaginal ultrasound examination has been shown to be an effective method of screening for this complication. The aim of the present study is to establish a reference range for cervical length measurement throughout gestation in twin pregnancies.

Conjoined twins pregnancies: experience with 36 cases from a single center.

To review a single center´s experience in the management of twin pregnancies with conjoined fetuses.

Selective fetoscopic laser photocoagulation of superficial placental anastomoses for the treatment of severe twin-twin transfusion syndrome

OBJECTIVE: To report our initial institutional experience with fetoscopic laser photocoagulation of placental anastomoses in severe twin-twin transfusion syndrome using a 1.0 mm endoscope. METHODS: Between July 2006 and June 2008, 19 monochorionic diamniotic twin pregnancies complicated by severe TTTS (Quintero stages III and IV) underwent fetoscopic laser therapy. Perinatal data were prospectively collected and compared according to the Quintero stages. RESULTS: Nine patients were classified as stage III and ten as stage IV. The Mean gestational ages at diagnosis and procedure were 20 (range: 17–25) and 22.0 (range: 19.0–26.0) weeks, respectively, with no statistical difference between the two groups. Preterm premature rupture of the membranes occurred in two cases (10.5%), and spontaneous preterm delivery in eight (42.1%). Overall mean gestational age at delivery was 32.1 (range: 26.0–38.0) weeks. Prematurity was more severe in stage IV patients (p<0.01). Among all cases, the overall survival rate was 52.6%, and the percentages of pregnancies with survival of both babies and at least one twin were 26.3% and 78.9%, respectively. In the case of stage III patients, the overall survival rate was 61.1%. Of the stage III pregnancies, 33.3% resulted in both babies surviving, and 88.9% of these pregnancies resulted in at least one surviving twin. For stage IV, as the corresponding statistics were 45.0%, 20.0% and 70.0% respectively. CONCLUSIONS: Our initial institutional experience with 1.0 mm fetoscopic laser therapy for severe TTTS showed results similar to those reported in the literature for larger endoscopes.

Longitudinal reference ranges for fetal ultrasound biometry in twin pregnancies

OBJECTIVE: The purpose of this study was to establish longitudinal reference ranges for fetal ultrasound biometry measurements and growth parameters in twin pregnancies. METHOD: A total of 200 uncomplicated twin pregnancies before 21 weeks of gestation were recruited for this prospective, longitudinal study. Women who abandoned follow-up, pregnancies with unknown outcomes or pregnancies with complications were excluded. Ultrasound scans were performed every three weeks, and biparietal and occipitofrontal diameters, head and abdominal circumferences, and femur diaphysis length measurements were obtained for each fetus at each visit. Estimated fetal weight, biparietal/occipitofrontal diameter, head circumference/abdominal circumference, and femur diaphysis length/abdominal circumference ratios were also calculated. Multilevel regression analysis was performed on normalized data. RESULTS: A total of 807 ultrasound examinations were performed in 125 twin pregnancies between 14 and 38 weeks of gestation (6.5±1.4 scans/pregnancy). Regression analysis demonstrated significant correlations for all variables with gestational age, namely log of the biparietal diameter (r = 0.98), log of the occipitofrontal diameter (r = 0.98), log of the head circumference (r = 0.99), log of the abdominal circumference (r = 0.98), square root of the femur length (r = 0.99), log of the estimated fetal weight (r = 0.99), biparietal/occipitofrontal ratio (r = -0.11), head/abdomen circumference ratio (r = -0.56), and log of the femur length/abdominal circumference ratio (r = 0.61). Values corresponding to the 10th, 50th, and 90th percentiles for estimated fetal weight at 28, 32, and 36 weeks, respectively, were as follows: 937, 1,096, 1,284 g; 1,462, 1,720, 2,025 g; and 2,020, 2,399, 2,849 g. CONCLUSION: In twin pregnancies, fetal ultrasound biometry measurements and growth parameters show a significant correlation with gestational age.

Correlation between the Doppler velocimetry findings of the uterine arteries during the first and second trimesters of pregnancy

OBJECTIVES Evaluate the feasibility of transvaginal uterine artery Doppler examination in the first and second trimesters of pregnancy, establish reference ranges in a Brazilian population and examine the correlation between these Doppler findings. METHODS Longitudinal prospective study at the antenatal clinic of a tertiary teaching hospital. Uterine artery Doppler examinations were carried out transvaginally at 11 to 14 weeks and 20 to 25 weeks of gestation. Uterine artery mean pulsatility index (PI) distributions were determined and the presence or absence of an early diastolic notch was also noted. The degree of correlation between first and second trimester Doppler findings was examined. RESULTS Three hundred and forty four women with live singleton pregnancies and normal outcome were first examined at a mean gestation of 12.7 weeks. The values corresponding to the 50th and 95th centiles of mean PI were 1.69 and 2.48. Bilateral notches were observed in 44% of cases and unilateral notches were present in 19%. Second trimester Doppler examinations were carried out at a mean gestation of 23.2 weeks and corresponding figures for the 50th and 95th centiles were 1.03 and 1.57. Bilateral notches were noted in 4.4% of the cases. First trimester impedance indices were significantly higher and positively correlated to second trimester findings (r = 0.42, p<0.0001). CONCLUSION Uterine artery Doppler examination can be successfully performed transvaginally and incorporated into scans that are routinely offered to women during their antenatal care in the first and second trimesters. Doppler indices obtained during the first trimester are significantly higher than those of the second trimester and findings at both scans are significantly correlated.