Nahla Khalek

A SONOGRAPHIC SHORT CERVIX AS THE ONLY CLINICAL MANIFESTATION OF INTRA-AMNIOTIC INFECTION

Abstract Objective: A sonographically short cervix is a powerful predictor of spontaneous preterm delivery. However, the etiology and optimal management of a patient with a short cervix in the mid-trimester of pregnancy remain uncertain. Microbial invasion of the amniotic cavity (MIAC) and intra-amniotic inflammation are frequently present in patients with spontaneous preterm labor or acute cervical insufficiency. This study was conducted to determine the rate of MIAC and intra-amniotic inflammation in patients with a cervical length <25 mm in the mid-trimester. Study design: A retrospective cohort study was conducted of patients referred to our high risk clinic because of a sonographic short cervix or a history of a previous preterm birth. Amniocenteses were performed for the evaluation of MIAC and for karyotype analysis in patients with a short cervix. Fluid was cultured for aerobic and anaerobic bacteria, as well as genital mycoplasmas. Patients with MIAC were treated with antibiotics selected by their physician. Results: Of 152 patients with a short cervix at 14–24 weeks, 57 had amniotic fluid analysis. The prevalence of MIAC was 9% (5/57). Among these patients, the rate of preterm delivery (<32 weeks) was 40% (2/5). Microorganisms isolated from amniotic fluid included Ureaplasma urealyticum (n=4) and Fusobacterium nucleatum (n=1). Patients with a positive culture for Ureaplasma urealyticum received intravenous Azithromycin. Three patients with Ureaplasma urealyticum had a sterile amniotic fluid culture after treatment, and subsequently delivered at term. The patient with Fusobacterium nucleatum developed clinical chorioamnionitis and was induced. Conclusion: (1) Sub-clinical MIAC was detected in 9% of patients with a sonographically short cervix (<25 mm); and (2) maternal parenteral treatment with antibiotics can eradicate MIAC caused by Ureaplasma urealyticum. This was associated with delivery at term in the three patients whose successful treatment was documented by microbiologic studies.

Clinical significance of the presence of amniotic fluid 'sludge' in asymptomatic patients at high risk for spontaneous preterm delivery.

To determine the clinical significance of the presence of amniotic fluid (AF) ‘sludge’ among asymptomatic patients at high risk for spontaneous preterm delivery.

What is amniotic fluid ‘sludge’?

The presence of free-floating hyperechogenic material within the amniotic fluid in close proximity to the uterine cervix (Figures 1 (cover) and ​and22 and Videoclips S1 and S2) has been described previously in women with an episode of preterm labor1, in women with a history of preterm delivery or threatened preterm labor2, and in asymptomatic women at risk for spontaneous preterm delivery in the mid-trimester of pregnancy3. We have proposed the term amniotic fluid ‘sludge’ to refer to this sonographic finding and provided evidence that ‘sludge’ is an independent risk factor for impending preterm delivery, histological chorioamnionitis and microbial invasion of the amniotic cavity in patients with spontaneous preterm labor and intact membranes1. Moreover, amniotic fluid ‘sludge’ has been identified in asymptomatic women at risk for spontaneous preterm delivery in the mid-trimester of pregnancy and is also an independent risk factor for preterm prelabor rupture of membranes (PROM) and spontaneous preterm delivery3. To determine the nature of amniotic fluid ‘sludge’, the material collected under sonographic guidance was examined under the microscope and microbiological studies were performed. Figure 1 Rendered three-dimensional transvaginal ultrasound image demonstrating the presence of amniotic fluid ‘sludge’ in close proximity to the cervix. Figure 2 Two-dimensional ultrasound image showing amniotic fluid ‘sludge’ in a patient with a short cervix and a cervical funnel. acute necrotizing chorioamnionitis (Figure 5a) and acute funisitis (Figure 5b). The newborn was admitted to the neonatal ...

Radiofrequency ablation vs bipolar umbilical cord coagulation in the management of complicated monochorionic pregnancies

The application of radiofrequency ablation (RFA) termination procedures to complicated cases involving monochorionic twins offers the potential of a less invasive option when compared to endoscopic techniques. The purpose of this study was to compare outcomes between these two techniques.

Fetal Myelomeningocele Repair: The Post-MOMS Experience at the Children's Hospital of Philadelphia

Background: Fetal myelomeningocele (fMMC) repair has become accepted as a standard of care option in selected circumstances. We reviewed our outcomes for fMMC repair from referral and evaluation through surgery, delivery and neonatal discharge. Material and Methods: All patients referred for potential fMMC repair were reviewed from January 1, 2011 through March 7, 2014. Maternal and neonatal data were collected on the 100 patients who underwent surgery. Results: 29% of those evaluated met the criteria and underwent fMMC repair (100 cases). The average gestational age was 21.9 weeks at evaluation and 23.4 weeks at fMMC repair. Complications included membrane separation (22.9%), preterm premature rupture of membranes (32.3%) and preterm labor (37.5%). Average gestational age at delivery was 34.3 weeks and 54.2% delivered at ≥35 weeks. The perinatal loss rate was 6.1% (2 intrauterine fetal demises and 4 neonatal demises); 90.8% of women delivered at the Childrens Hospital of Philadelphia and 3.4% received transfusions. With regard to the neonates, 2 received ventriculoperitoneal shunts prior to discharge; 71.1% of neonates had no evidence of hindbrain herniation on MRI. Of the 80 neonates evaluated, 55% were assigned a functional level of one or more better than the prenatal anatomic level. Conclusion: In an experienced program, maternal and neonatal outcomes for patients undergoing fMMC repair are comparable to results of the MOMS trial.

Comparison of ultrasound and magnetic resonance imaging parameters in predicting survival in isolated left‐sided congenital diaphragmatic hernia

To compare test characteristics of ultrasound‐ and magnetic resonance imaging (MRI)‐derived parameters in predicting newborn survival in cases of isolated left‐sided congenital diaphragmatic hernia (CDH).

Maximal amniotic fluid index as a prognostic factor in pregnancies complicated by polyhydramnios

Polyhydramnios is present in approximately 2% of pregnancies and has been associated with a variety of adverse pregnancy outcomes. Our aim was to evaluate the association between the maximal amniotic fluid index (AFI) and the frequency of specific adverse outcomes.

Management of prenatally diagnosed lung lesions

Prenatal diagnosis provides insight into the in utero evolution of fetal thoracic lesions such as congenital cystic adenomatoid malformation (CCAM), bronchopulmonary sequestration (BPS), or hybrid lesions. Serial sonographic study of fetuses with thoracic lesions has helped define the natural history of these lesions, determine the pathophysiologic features that affect clinical outcome, and formulate in utero and postnatal management based on prognosis.

Low-Dose Fetal CT in the Prenatal Evaluation of Skeletal Dysplasias and Other Severe Skeletal Abnormalities

OBJECTIVE Prenatal diagnosis of skeletal dysplasia is often difficult and based on findings with ultrasound, a technique with 40-60% sensitivity. The purpose of this study was to evaluate a preliminary experience in assessing severe prenatal osseous abnormalities with low-dose fetal CT. The hypothesis was that use of CT may improve the prenatal diagnosis of skeletal dysplasia beyond the available capabilities of ultrasound. MATERIALS AND METHODS Retrospective search of a radiology database (July 2008-February 2011) yielded the records of unenhanced CT examinations of patients referred because of abnormal fetal bones. The original ultrasound and CT reports as interpreted at image acquisition were independently analyzed by two radiologists blinded to the final diagnosis and to the findings of the opposing imaging modality. Blinded review of the images was also performed. Correlation was made with the postmortem and postnatal findings. RESULTS According to the reports of the studies, 5 of 21 cases were interpreted correctly with CT and incorrectly with ultrasound. In 17 cases, CT revealed additional osseous findings not in the ultrasound report. There were no cases in which ultrasound findings were correct and CT findings were incorrect. Blinded review of the images revealed that CT outperformed ultrasound (p < 0.001). There were a total of four CT errors among 218 total measures recorded and a total of 19 ultrasound errors among 218 total measures. CONCLUSION Although low-dose fetal CT should never be used as the initial diagnostic modality in cases of suspected skeletal dysplasia, it is a powerful imaging adjunct that depicts the fetal bones in exquisite detail. Use of CT of fetuses at risk of skeletal dysplasia may provide clinicians with more accurate information for counseling of families regarding neonatal morbidity and mortality.

Impact of Mode of Delivery on Markers of Perinatal Hemodynamics in Infants with Hypoplastic Left Heart Syndrome

OBJECTIVE To determine whether the mode of delivery of infants prenatally diagnosed with hypoplastic left heart syndrome (HLHS) affects markers of perinatal hemodynamics. STUDY DESIGN A retrospective review of patients diagnosed prenatally with HLHS and delivered within our institution was undertaken. Arterial blood gases, echocardiographic data, and markers of end organ function were compared based on route of delivery. RESULTS A total of 79 infants with HLHS were enrolled between January 2002 and December 2008. The infants delivered by elective cesarian delivery (CD) had younger gestational age compared with those delivered by vaginal delivery (VD) or by urgent CD/operative VD. Those delivered by elective CD had lower pH and higher partial pressure of CO(2) on arterial cord blood gas analysis. There were no differences in partial pressure of O(2) and base deficit among the 3 study groups. One-minute and 5-minute Apgar scores, markers of end organ function, echocardiographic parameters, length of hospitalization, and survival to discharge were similar among the groups. CONCLUSIONS Overall, newborns with a prenatal diagnosis of HLHS transitioned well to extrauterine life without significant acidosis regardless of the mode of delivery. Delivery of newborns with HLHS by elective CD did not demonstrate any hemodynamic advantage over VD in our cohort of patients.