Marius Kublickas

Detection of malformations in chromosomally normal fetuses by routine ultrasound at 12 or 18 weeks of gestation : a randomised controlled trial in 39 572 pregnancies

Objective  To compare the antenatal detection rate of malformations in chromosomally normal fetuses between a strategy of offering one routine ultrasound examination at 12 gestational weeks (gws) and a strategy of offering one routine examination at 18 gws.

Routine measurements of umbilical artery lactate levels the prediction of perinatal outcome

OBJECTIVE Our purpose was to compare lactate levels with acid-base balance in the umbilical artery with respect to the prediction of pregnancy outcome. STUDY DESIGN A prospective study of 4045 cord samples was performed. Lactate was measured with a new method that requires 5 microliters of blood and provides the result within 1 minute. RESULTS The umbilical artery lactate concentrations were significantly elevated in instrumental deliveries (2.65 +/- 1.2 mmol/L) and in emergency cesarean sections (2.44 +/- 1.7 mmol/L) compared with spontaneous vaginal delivery (1.87 +/- 0.94 mmol/L) (p < 0.001, p < 0.001). Lactate correlated significantly to fetal pH, hemoglobin, base deficit, PCO2, and HCO3-. Lactate was comparable to pH and base deficit in sensitivity, specificity, and positive and negative predictive values in relation to morbidity and mortality. CONCLUSION Umbilical artery lactate concentration and acid-base balance predicted perinatal outcomes with similar efficacies; however, its simplicity makes lactate analysis an interesting alternative in obstetric care.

Ultrasound dating at 12–14 weeks of gestation. A prospective cross‐validation of established dating formulae in in‐vitro fertilized pregnancies

To determine the accuracy of established ultrasound dating formulae when used at 12–14 weeks of gestation.

Effects of nitroglycerin on the uterine and umbilical circulation in severe preeclampsia

Objective To determine the effects of nitroglycerin on placental circulation in severe preeclampsia. Methods Twelve women with severe preeclampsia were examined. Uterine and umbilical artery pulsatility indices (PI) were assessed by pulsed Doppler ultrasound before and after infusion of nitroglycerin, starting at 0.25 μg/kg per minute with stepwise dosage increases until a diastolic blood pressure (BP) of 100 mmHg was achieved. Blood pressure and heart rate were recorded every 5 minutes. Blood was sampled for analysis of the second messenger of nitric oxide, cyclic guanosine monophosphate (cGMP), before and at the end of the infusion. Results During the infusion, the mean systolic BP de-creased from 161 (95% confidence interval [CI] 154–169) to 138 mmHg (95% CI 131–146), and the diastolic pressure decreased from 116 (95% CI 111–122) to 103 (95% Cl 96–110) mmHg (P < .01). The PI of the uterine artery did not change significantly (1.23 [95% CI 1.01–1.61]) versus 1.30 [95% CI 1.01–1.88]), whereas umbilical artery PI decreased significantly (P < .01), from 1.35 (95% CI 1.09–1.73) to 1.20 (95% CI 1.05–1.40), with a more pronounced decrease in patients with high basal values. Cyclic GMP remained essentially unchanged (6.4 [95% CI 5.4–7.71 versus 5.5 [4.7–6.6] nmol/L). Conclusion The reduction in the PI of the umbilical artery during nitroglycerin-induced BP reduction implies vasodilation in the umbilical circulation. The absence of an increase in cGMP does not support the view that the nitroglycerin effect is reflected by the plasma concentration of cGMP.

Routine ultrasound examination at 12 or 18 gestational weeks for prenatal detection of major congenital heart malformations? A randomised controlled trial comprising 36 299 fetuses.

Objective  To compare the rate of prenatal diagnosis of heart malformations between two policies of screening for heart malformations.

The Stockholm classification of stillbirth

Objective. To design and validate a classification system for audit groups working with stillbirth. The classification includes well‐defined primary and associated conditions related to fetal death. Design. Descriptive. Setting. All delivery wards in Stockholm. Population. Stillbirths from 22 completed weeks in Stockholm, Sweden. Methods. Parallel to audit work, the Stockholm stillbirth group has developed a classification of conditions related to stillbirth. The classification has been validated. Main outcome measure. The classification and the results of the validation are presented. Result. The classification with 17 groups identifying underlying conditions related to stillbirth (primary diagnoses) and associated factors which may have contributed to the death (associated diagnoses) is described. The conditions are subdivided into definite, probable and possible relation to the death. An evaluation of 382 cases of stillbirth during 2002–2005 resulted in 382 primary diagnoses and 132 associated diagnoses. The most common conditions identified were intrauterine growth restriction/placental insufficiency (23%), infection (19%), malformations/chromosomal abnormalities (12%). The ‘unexplained’ group together with the ‘unknown’ group comprised 18%. Validation was done by reclassification of 95 cases from 2005 by six investigators. The overall agreement regarding primary diagnosis was substantial (kappa=0.70). Conclusions. The Stockholm classification of stillbirth consists of 17 diagnostic groups allowing one primary diagnosis and if needed, associated diagnoses. Diagnoses are subdivided according to definite, probable and possible relation to stillbirth. Validation showed high degree of agreement regarding primary diagnosis. The classification can provide a useful tool for clinicians and audit groups when discussing cause and underlying conditions of fetal death.

Screening for Down syndrome based on maternal age or fetal nuchal translucency: a randomized controlled trial in 39,572 pregnancies.

Nuchal translucency (NT) screening increases antenatal detection of Down syndrome (DS) compared to maternal age‐based screening. We wanted to determine if a change in policy for prenatal diagnosis would result in fewer babies born with DS.

Diverse Mechanisms of Endothelium-Derived Hyperpolarizing Factor-Mediated Dilatation in Small Myometrial Arteries in Normal Human Pregnancy and Preeclampsia

This ex vivo study focuses on the mechanisms of endothelium-dependent dilatation in the uterine circulation of normal pregnancy (n = 12) and in women with preeclampsia (n = 12). Arteries (internal diameter, ∼250 μm) isolated by myometrial biopsy from women undergoing planned cesarean delivery or delivery as a result of the deterioration of preeclampsia were studied using a wire myograph. Bradykinin-induced dilatation was assessed in the presence and/or absence of pharmacological inhibitors to determine the contribution of nitric oxide and endothelium-derived hyperpolarizing factor (EDHF), as well as that of EDHF-mediated pathways such as myoendothelial gap junctions (MEGJs) and products of arachidonic acid, H2O2 and cytochrome P450 2C9 (CYP2C9). Transmission electron microscopy was used to visualize morphological prerequisites for MEGJs. In normal pregnancy, EDHF through MEGJs appeared to be a predominant mediator conferring endothelium-dependent relaxation in small myometrial arteries. In preeclampsia, bradykinin-induced relaxation was reduced via compromised EDHF-type responses, in which the contribution of MEGJs became negligible. The attenuated role of MEGJs to endothelium-dependent relaxation was partly compensated through the contribution of H2O2 or other endothelium-derived relaxing factors. CYP2C9 products of arachidonic acid had no effect on EDHF-type relaxation in arteries of women with normal pregnancy or with preeclampsia. We suggest that EDHF-type responses via MEGJs are primarily targeted in small myometrial arteries in women with preeclampsia. This could significantly contribute to the impaired uteroplacental blood flow in this disorder.

Correlation between ultrasound and autopsy findings after 2nd trimester terminations of pregnancy.

Abstract Objective: To compare ultrasound (US) and fetal autopsy findings in 2nd trimester termination of pregnancy because of structural fetal anomalies. Methods: A total of 112 terminations of pregnancy (TOP) between 1999–2003 were reviewed retrospectively. The cases originated from a secondary and a tertiary Fetal Medicine unit in the south Stockholm area, using a common specialized perinatal pathology service. Karyotype was not known at the time of US examination. The findings were compared and classified into four groups according to the degree of agreement between US and autopsy. Results: In 45% of cases there was total agreement between US and autopsy. In 40%, autopsy confirmed all US findings but provided additional information of clinical importance. Partial or total lack of agreement was noted in 11% and 4% of the cases, respectively. Areas of discrepancy involved mainly CNS- and cardiovascular abnormalities and, to a lesser extent, renal anomalies, abdominal wall defects and hydrops/hygroma. Regarding CNS abnormalities the overall rate of agreement was 62%; it was highest in acrania/anencephaly (92%) and lowest in hydrocephaly (39%). Conclusion: We find an overall high degree of agreement between US and autopsy findings. Autopsy often provided additional information of clinical value and it should always follow US examination and TOP. Fixation of CNS is crucial for optimal results. Specific limitations of autopsy, i.e., detection of CNS abnormalities, may be reduced by complementary imaging techniques, such as MRI. The ability of US to detect cardiac anomalies is enhanced with the close contact to specialized fetal cardiology.

Causes of stillbirth at different gestational ages in singleton pregnancies.

To compare causes of stillbirth in preterm and term pregnancies.