Michelle Smith-Levitin

How accurate is fetal biometry in the assessment of fetal age

OBJECTIVE The purpose of the study was to assess the accuracy of fetal biometry in the midtrimester of pregnancy in the assignment of fetal age. STUDY DESIGN A total of 152 singleton, 67 twin, and 19 triplet gestations resulting from in vitro fertilization with ultrasonographic fetal biometry from 14 to 22 weeks made up the study population. A gestational age prediction equation was derived from singletons with the use of stepwise linear regression. This equation was compared with 38 previously published equations and then applied to the twin and triplet populations. RESULTS Head circumference was the best predictor of gestational age (random error [SD] 3.77 days). Addition of abdominal circumference and femur length to head circumference improved the accuracy of the dating equation (random error 3.35 days). Most dating formulas had systematic errors of <1 week. The systematic error was -0.32 day for averaging the singleton-based predictions for twins and -1.26 days for triplets. CONCLUSIONS Gestational age assessment with the use of fetal biometry from 14 to 22 weeks is accurate for singleton, twin, and triplet gestations.

Selective reduction of multifetal pregnancies to twins improves outcome over nonreduced triplet gestations.

OBJECTIVE Our purpose was to evaluate effects of multifetal pregnancy reduction on pregnancy complications and birth weights of remaining twin fetuses compared with expectantly managed triplets and nonreduced twins. STUDY DESIGN Medical records of 54 triplet pregnancies, 59 twin pregnancies resulting from multifetal pregnancy reduction, and 88 sets of twins conceived with assisted reproductive techniques and delivered at New York Hospital after 24 weeks were retrospectively reviewed. Birth weights were corrected for gestational age at delivery by use of a formula derived from composite standardized growth curves. Statistical analysis was performed with chi(2) analysis and Student t test. RESULTS Twins remaining after reduction and nonreduced twins were less likely to have preeclampsia than were triplets (14% and 23% vs 30%) and to be delivered before 36 weeks (39% and 27% vs 72%). They had birth weights that were > 100 gm larger than those of triplets even when corrected for gestational age. Reduced twins were similar to nonreduced twins in all parameters studied. CONCLUSIONS Multifetal pregnancy reduction results in pregnancy complications, gestational age, and birth weights closer to those of nonreduced twins than to expectantly managed triplets.

Umbilical Cord Stricture and Overcoiling Are Common Causes of Fetal Demise

Although umbilical cord stricture and umbilical cord overcoiling have been established as causes of intrauterine fetal demise, relatively few studies addressed this issue, most of them being case reports. We reviewed a total of 268 fetal autopsies during a 3-year period from 1998 to 2001. One hundred thirty nine cases of fetal demise including spontaneous abortion were identified. Nineteen percent (26 of 139) were associated with umbilical cord stricture, overcoiling, or a combination of both. Stricture of the umbilical cord was defined as a decrease in diameter in relation of the remaining umbilical cord; overcoiling as 0.3 coil/cm or greater. Fetal demise most commonly occurred in the second trimester, with a mean gestation age of 21 weeks. The average maternal age was 33 years; 15% had a prior fetal demise. We found that 77% (20 of 26) of these cases had umbilical cord stricture only or with overcoiling, 23% (6 of 26) had umbilical cord overcoiling alone. Localized deficiency of Whartons jelly and increased collagen were found in all cases with umbilical cord stricture with or without overcoiling. In patients with umbilical cord overcoiling alone, 25% had Whartons jelly deficiency; half of them had increased collagen deposition in the umbilical cords. The placenta was reviewed for secondary thrombosis of the vessels of the chorionic plate. Thrombosis of the vessels of the chorionic plate was noted in 54% of the patients. Our study suggests that umbilical cord stricture and cord overcoiling may represent two distinct pathological entities commonly causing fetal demise. This observation reinforces the importance of a fetal autopsy with careful examination of the placenta and umbilical cord with documentation of the cord coil index.

Multiple gestations from in vitro fertilization: successful implantation alone is not associated with subsequent preeclampsia.

OBJECTIVE Our purpose was to compare the risk for preeclampsia and severe preeclampsia in triplet and twin gestations and to evaluate the effect of successful implantation on the development of preeclampsia and on perinatal outcome in triplet pregnancies conceived by means of in vitro fertilization. STUDY DESIGN A case control study was conducted of triplet pregnancies (n = 38) matched for maternal age, parity, race, and delivery date with twin pregnancies (n = 38) resulting from a single fetal reduction (spontaneously or by means of multifetal pregnancy reduction) after successful implantation of triplets. All pregnancies were conceived by means of in vitro fertilization. Rates of preeclampsia and other maternal complications, factors affecting implantation, and perinatal outcomes were compared. Preeclampsia and severe preeclampsia were defined by The American College of Obstetricians and Gynecologists criteria. The Student t test and the chi(2) test were used for statistical analysis. RESULTS The triplet group had a higher rate of severe preeclampsia (26.3%) than the twin (reduced triplet) group (7.9%). The prevalence of preeclampsia (mild and severe combined) also was higher among the triplet group (44.7%) than among the twin group (15.8%). There was no difference in other maternal complications of pregnancy or in factors potentially affecting implantation, such as assisted hatching. Mean fetal weight was lower among the triplet group, but gestational age at delivery was not significantly different. CONCLUSIONS The rate of preeclampsia is higher among triplets conceived by means of in vitro fertilization than among triplets conceived by means of in vitro fertilization and reduced to twins. This finding suggests that fetal number, placental mass, or factors unrelated to the success of implantation are more important to the development of preeclampsia than is successful implantation alone.

Cephalhematoma and caput succedaneum: Do they always occur in labor?

OBJECTIVE Our purpose was to analyze our experience with cephalhematomas detected prenatally by ultrasonography. STUDY DESIGN Seven cases of cephalhematomas were identified prenatally among 16,292 fetuses having comprehensive ultrasonographic examinations between 1993 and 1996. The course of pregnancy and the neonatal outcome were reviewed in each case. RESULTS Cephalhematomas appeared as an echogenic bulge posterior to the occipital region (5 cases) or at the temporal region of the fetal head (2 cases). CONCLUSION Cephalhematomas, which are believed to be a result of operative delivery, can also originate, in utero, antepartum. Premature rupture of membranes appears to be an associated factor.

Severe Hyponatremia Associated with Use of Black Cohosh during Prolonged Labor and Unsuccessful Home Birth

Introduction There has been an increase in the use of herbal supplements during pregnancy, which are frequently of unproven efficacy and safety. We present a case of severe hyponatremia and altered mental status associated with the use of black cohosh during prolonged labor. Case A 39-year-old primigravida at 385/7 weeks of gestational age presented to the emergency department after she became disoriented and lethargic while laboring at home with a midwife. She had consumed several doses of black cohosh to induce and augment labor. On presentation, she was nonverbal and unable to follow commands. Her serum sodium was 114 mmol/L (range, 132–145 mmol/L), serum osmolality was 253 mOsm/kg (range, 275–300 mOsm/kg), urine osmolality was 190 mOsm/kg (range, 300–900 mOsm/kg), and urine sodium was <10 mmol/L. The patient soon became uncooperative and combative and a cesarean section was performed. Postoperatively, she was transferred to the intensive care unit for monitoring and correction of her sodium. Her mental status returned to baseline and she was subsequently discharged home without further complication. Discussion Clinically significant hyponatremia associated with pregnancy is rare. Further investigation is needed to evaluate the safety and efficacy of black cohosh and other commonly used herbal supplements during pregnancy and labor.

Antepartum Mastitis: A Case Report

Background: Acute mastitis commonly occurs in the postpartum period. It has been reported only rarely in the antepartum period. Case: A 14-year-old patient presented at 29 weeks gestation with her symptoms and examination consistent with bilateral mastitis that had worsened over 2 months. She had evidence of systemic infection. She was treated with parenteral antibiotics and local skin care. She gradually improved and delivered a healthy infant at term. Conclusion: The management of antepartum mastitis can be derived from experience with puerperal mastitis. It must include early recognition, a search for predisposing factors and causative organisms, and aggressive treatment. Such an approach can lead to successful pregnancy outcome with minimal fetal or maternal morbidity.

A Honeycomb Appearance of the Fetal Choroid Plexus

A honeycomb appearance of the choroid plexus in second-trimeste fetuses was first described by Nyberg et al who reported four fetuses with multiple small cysts that formed a “honeycomb” appearance. This is a report of an experience with this entity in second-trimeste fetuses referred for comprehensive ultrasound examination and genetic amnio-centesis.