R. Achiron

Low-back pain of pregnancy

Background. Low‐back pain (LBP) is a commonly observed symptom during pregnancy. Despite its high frequency the extent of the problem is less well documented and detailed studies concerning related risk factors are scarce. Furthermore, efforts to address the problem are hampered by the inability to predict accurately which pregnancies are at risk. This study was conducted in order to assess the frequency, manifestations and the contribution of various factors to the development of LBP during pregnancy.

Prenatal ultrasonographic diagnosis of fetal heart echogenic foci: No correlation with Down syndrome

Objective To determine whether karyotype is indicated when fetal heart echogenic foci are encountered on prenatal sonogram. Mehtods Pregnant women who presented at two large district hospitals in Israel that treat 7200 gravidas per year, and in whom fetal heart echogenic foci were diagnosed, were studied prospectively. Identified cases had detailed prenatal and postnatal echocardiographic examinations, and pregnancy outcome was assessed. Results During 18 months, 2214 low-risk pregnant women were examined sonographically, and 163 (7.4%) cases of fetal heart echogenic foci were detected at the first transvaginal sonography at 13-16 weeks gestation. On a repeat scan at 20-22 weeks gestation, 59.5% of the foci could not be identified, leaving only 66 (3%) cases for postnatal evaluation. Left ventricle-right ventricle ratio for location of the fetal heart echogenic foci was 3:1; 4.9% of all cases had bilateral findings. The karyotypes of 16 fetuses were normal and no additional abnormalities were found. The remaining 50 cases were normal in appearance at delivery without any features that suggested trisomy 21. A review of the English language literature revealed that six of 489 cases with fetal heart echogenic foci (1.2%) had trisomy 21. However, statistical analysis of a hypothetical sample that produced these six cases revealed that the calculated risk of trisomy 21 in a fetus with fetal heart echogenic foci is about 0.002%. Conclusion Karyotyping is unwarranted in the midtrimester fetus with incidental findings of fetal heart echogenic foci.

The development of the fetal vermis: anin-uterosonographic evaluation: Fetal vermis and prenatal sonographic evaluation

To establish a nomogram for fetal vermis measurements during gestation.

Noonan syndrome: A cryptic condition in early gestation

Noonan syndrome is one of the most common of genetic syndromes and manifests at birth, yet it is usually diagnosed during childhood. Although prenatal diagnosis of Noonan syndrome is usually not possible, in a few cases the ultrasonographic findings suggested the diagnosis in utero. Reported sonographic clues include septated cystic hygroma, hydrothorax, polyhydramnios, and cardiac defects, such as pulmonic stenosis and hypertrophic cardiomyopathy. During a 6-year period, 46,224 live-born infants were delivered at the Chaim Sheba Medical Center. Seven newborn infants and four fetuses were found to have Noonan syndrome. One fetus showed transient nuchal translucency of 4 mm and bilateral neck cysts at the 13th gestational week. Both findings resolved spontaneously by the 18th gestational week, but during the third trimester this fetus developed hydrothorax, skin edema, and polyhydramnios. In the three other fetuses, first- and second-trimester ultrasonographic findings were normal, and the diagnosis of Noonan syndrome was suggested only during the third trimester. All three fetuses had polyhydramnios and skin edema. A cardiac malformation, hydrothorax, and a large head were present in one fetus. Sonographic facial findings were investigated. In all four fetuses posteriorly angulated, apparently low-set ears and depressed nasal bridge were identified. Wide nasal base was seen in two fetuses. In two fetuses, persistent opening of the fetal mouth was interpreted as fetal hypotonia. One fetus developed progressive postnatal hypertrophic cardiomyopathy and in one case, pulmonic stenosis became apparent at age 6 months. This small series suggests that Noonan syndrome has an evolving phenotype during in utero and postnatal life. Amelioration of early nuchal region findings and late onset of the more typical ultrasonographic changes may limit early prenatal detectability.

Rotation of the vermis as a cause of enlarged cisterna magna on prenatal imaging

Dandy–Walker complex is a continuum of developmental anomalies of the posterior fossa which includes vermian rotation. However, vermian rotation alone may be benign. The aim of this study was to describe our experience with sagittal‐plane prenatal ultrasound in the diagnosis of rotation of the vermis in cases of suspected enlarged cisterna magna on routine antenatal imaging, and to describe the follow‐up of these patients.

Fetal aortic arch measurements between 14 and 38 weeks' gestation: in-utero ultrasonographic study.

Objectiveu2003To establish in‐utero reference ranges for fetal transverse aortic arch diameter (TAD) and distal aortic isthmus diameter (DAID) using high‐resolution ultrasound techniques.

Intravenous immunoglobulin treatment for recurrent abortions caused by antiphospholipid antibodies

There is an association between the presence of antibodies that bind to anionic phospholipids and the occurrence of repeated spontaneous abortion. Many uncontrolled studies have reported favorable pregnancy outcome in women treated with steroids, low-dose aspirin, heparin, or their combination. Similarly, treatment failures have been reported with most of these therapeutic regimens. Immunoglobulins play a central role in immune regulation. A wide spectrum of human diseases are associated with decreased or abnormal regulation of Ig levels. Recently, IV preparations of Ig have become available for clinical use, including treatment of patients with recurrent abortions and high levels of antiphospholipid antibodies. The effectiveness of this new mode of therapy can be related to several immunological mechanisms such as blockade of antibody binding to receptors on macrophages, increase in T suppressor cells, or decrease in antibody synthesis. The latter effect may be mediated by anti-idiotypic antibodies in the Ig preparation. Determination of dosage of IV Ig, duration of treatment, and treatment intervals are all empirical in patients with recurrent abortions and high levels of antiphospholipid antibodies because antiphospholipid antibody levels are not useful for monitoring therapy. Although the data available at present are promising, additional randomized trials are needed to determine the efficacy of IV Ig in patients with immunological recurrent abortions.

Axial growth of the fetal eye and evaluation of the hyaloid artery: in utero ultrasonographic study

The aims of this prospective, cross‐sectional study were to report axial ocular growth during human gestation, to determine the presence of the hyaloid artery (HA) and its blood flow, and to provide a timetable for HA regression. The study group comprised 231 low‐risk singleton pregnancies between 14 and 38 weeks gestation. Ocular axial length (OAL), anterior chamber depth (ACD) and posterior chamber depth (PCD) were measured using high‐resolution ultrasound. The growth of these eye segments in correlation with gestational age (GA) was established. The presence of the HA and its regression were determined. By using power Doppler, ultrasound blood flow within the HA was estimated. HA regression is a gradual process that is not evident before 18 weeks gestation. In all fetuses beyond 29 weeks gestation, no HA could be detected (P<0.001). Blood flow within the HA was documented only until the 16th week of gestation. The correlation coefficients, r=0.924, 0.784 and 0.929, for OAL, ACD and PCD, respectively, were found to be highly statistically significant (P<0.0001). The present data offer normative measurements of the fetal axial eye lengths, timetable for HA regression and flow cessation. Copyright

Outcome of twin pregnancies reduced from triplets compared with nonreduced twin gestations

Objective To compare the outcome of triplet pregnancies reduced to twins reached 24 weeks gestation with the outcome of twin pregnancies managed in the same perinatal department. Methods The study group included 43 triplet pregnancies reduced to twins reached 24 weeks gestation and were delivered between January 1989 and December 1993. The complications and outcomes of these pregnancies were compared with all 134 bichorionic twin pregnancies delivered during 1993. Results In general, the outcome of triplet pregnancies reduced to twins was not significantly different from that of twin pregnancies. Both pregnancy-induced hypertension and premature contractions were similar in the two groups. The higher incidence of premature repture of membranes (PROM) in the reduced cases compared with nonintervention twins (18.6 versus 8.2%) was of borderline significance (relative risk [RR] 2.27, 95% confidence interval [CI] 0.98–5.27). Although premature delivery occurred in 30% of patients in both groups, 20.9% of patients in the reduction group delivered before 35 weeks gestation, compared with 10.4% in the nonintervention group (RR 2.0, 95% CI 0.93–4.30). The mean gestational age was similar in the two groups, as was the risk of low birth] weight and respiratory disorders. Differences in the proportion of patients with PROM, low gestation duration, and very low birth weight, although not quite statistically significant, are probably because of the relatively small numbers and, hence, of low power (50–55%), but may be of clinical importance. Conclusion The outcome of triplet pregnancies reduced to twins did not differ substantially from that of nonreduced twin pregnancies.

The development of the foetal thyroid: in utero ultrasonographic measurements

The early recognition of potentially treatable thyroid disease in the foetus frequently depends on the detection of abnormal growth of the foetal thyroid gland. We have therefore established nomograms for foetal thyroid transverse width and circumference from 14 weeks of gestation until term, using transvaginal and transabdominal high‐resolution ultrasound techniques.