Ralph K. Tamura

Conservative treatment of ectopic pregnancy with methotrexate

Six subjects with distal ampullary ectopic pregnancies were treated with four doses of intravenous methotrexate (1.0 mg/kg) followed by four doses of leucovorin (0.1 mg/kg, intramuscularly). The diagnosis was established in all cases by laparoscopy following sonography and radioimmunoassay for serum beta subunit of human chorionic gonadotropin. Subjects were followed with daily quantitative serum beta-human chorionic gonadotropin radioimmunoassay and sonography. Five of the six subjects experienced resolution of their ectopic pregnancy without additional surgical treatment. One subject underwent salpingectomy following treatment. Morbidity also included three patients with mild stomatitis or gastritis, and two patients had transient elevations of serum transaminase levels. Two patients had protracted courses and received blood transfusions. The most abrupt response and most uncomplicated courses were experienced in the three subjects with initial human chorionic gonadotropin levels below 1000 mIU/ml. This preliminary experience suggests that methotrexate may be an effective alternative for the treatment of early ectopic pregnancy.

Predictive value sensitivity, and specificity of ultrasonic targeted imaging for fetal anomalies in gravid women at high risk for birth defects

In this report the predictive value of ultrasonic targeted imaging for fetal anomalies (TIFFA) is defined. Six hundred fifteen pregnant women at high risk for birth defects were scanned from January, 1980, to December, 1983. Follow-up evaluation was available on 569 fetuses. The pregnancies were classified into five groups according to the indications used for ultrasonic targeted imaging studies. The largest number of women were placed in group 1 and were referred because of a variety of abnormalities in previous or ongoing pregnancies. The women classified in the other four groups were examined because of maternal or fetal reasons related to specific craniospinal (29%), urinary (7.9%), gastrointestinal (6.7%), and skeletal (3.7%) defects. In our series the predictive values of abnormal and normal ultrasonic targeted imaging studies were 95% and 99%, respectively. A detailed breakdown of the accuracy of ultrasonic targeted imaging in relation to each anatomic category is presented; these data are useful in counseling gravid women with anomalous fetuses.

Diminished growth in fetuses born preterm after spontaneous labor or rupture of membranes

We examined biparietal diameter, abdominal circumference, and birth weight in 148 preterm infants to assess fetal growth. A statistically significant proportion of preterm fetuses had biparietal diameter and abdominal circumference values below the fiftieth and tenth percentile levels as compared with that expected in normal fetuses. Similarly, birth weight of infants in the study fell significantly below the fiftieth and tenth percentiles relative to Brenners curve. We conclude that diminished fetal growth is associated with early delivery secondary to preterm labor or preterm premature rupture of membranes or both. Additionally, since biparietal diameters in preterm fetuses are smaller than those of normal fetuses the prediction of gestational age by cephalometry should be advanced by 7 to 10 days.

A simple estimated fetal weight equation based on real-time ultrasound measurements of fetuses less than thirty-four weeks' gestation

Based on ultrasonographic mensuration, a number of equations have previously been devised for the purpose of estimating fetal weights. The objective of this study was to develop a mathematical equation that is simple, accurate, and easy to use when applied to preterm or low-birth weight fetuses (less than 2,500 gm). Real-time ultrasound measurements of fetal biparietal diameters (BPDs) and abdominal circumferences (ACs) were obtained in 62 pregnant women within one week of premature delivery. Mean gestational age and mean birth weight +/- SD for this study group of neonates were 28.5 +/- 3.5 weeks and 1,135 +/- 343 gm, respectively. With the aid of computer analysis, a simple regression equation was derived: EFW = (BPD x AC x 9.337) - 229. When predicted estimated fetal weight (EFW) was compared with actual birth weight (ABW), multiple regression analysis demonstrated a correlation coefficient (R) of 0.957. Preliminary results on 19 patients of a prospective study showed an absolute mean difference between the computed EFWs and the ABWs to be within 7.0% of ABW (70 gm/kg of ABW). The standard deviation of the difference was 9.3% of ABW (93 gm/kg of ABW). Based on these data, this simple equation appears to be clinically reliable and easy to use when estimating weights of preterm or low-birth weight fetuses of less than 2,500 gm.

The clinical significance of a single umbilical artery as an isolated finding on prenatal ultrasound

Objective To evaluate the perinatal outcome in fetuses with single umbilical artery detected on targeted prenatal ultra-sound without other anomalies. Methods During a 3.5-year period, an isolated single umbilical artery was suspected on prenatal ultrasound examination in 57 fetuses evaluated at two referral centers. Targeted imaging to rule out concurrent fetal anomalies was normal in all cases. Pregnancy and perinatal outcome data were retrieved by review of the medical records or from conversations with referring physicians. Complete follow-up was available in 50 cases. Results A two-vessel umbilical cord was confirmed at birth in 50 neonates. The mean gestational age at delivery was 38.6 ± 2.8 weeks; the mean birth weight was 3202.8 ± 835.8 g. Seventeen patients (34%) underwent genetic amniocentesis, and all fetuses had a normal karyotype. The only neonate ascertained to have a congenital anomaly after birth was diagnosed with total anomalous pulmonary venous return. This neonate underwent a corrective surgical procedure and is thriving with no apparent problems at 3.5 years of age. There were no perinatal deaths. Conclusion In the absence of additional sonographically detectable anomalies, an isolated single umbilical artery does not seem to affect clinical outcome and therefore should not alter routine obstetric management.

Meconium below the vocal cords at delivery: Correlation with intrapartum events

Intrapartum events were studied in 272 patients with meconium-stained amniotic fluid. All infants underwent DeLee suction followed by intubation and 58 of 272 had meconium present below the vocal cords at delivery. Neither the total duration of variable fetal heart rate decelerations or a continuous saltatory pattern nor the presence or absence of late decelerations could be related to an increased risk of meconium below the vocal cords. When a rising baseline fetal heart rate and decreased variability were present as well, a significantly greater proportion of patients had meconium below the vocal cords. Routine obstetric and pediatric suctioning did not prevent the single death that occurred in a fetus who had deep meconium aspiration in utero.

Isolated choroid plexus cyst(s): An indication for amniocentesis

OBJECTIVE Our purpose was to prospectively evaluate the risk of chromosomal abnormalities associated with isolated choroid plexus cyst(s) in gravid women undergoing second-trimester ultrasonographic examination. STUDY DESIGN During a 24-month period 9100 pregnant women underwent midtrimester ultrasonographic evaluation. Women with a fetal diagnosis of choroid plexus cyst(s) were offered amniocentesis and a repeat examination in 4 to 6 weeks. RESULTS A diagnosis of choroid plexus cyst(s) was made in 102 fetuses (1.1%). In four of these fetuses multiple congenital anomalies were noted. Three of the four fetuses had a chromosomal abnormality, two trisomy 18 and one unbalanced translocation, t(3;13). In the remaining 98 fetuses the choroid plexus cysts were isolated findings, that is, there were no other ultrasonographically detected anomalies. Seventy-five of these 98 fetuses underwent amniocentesis. An abnormal karyotype was identified in four fetuses: three had Down syndrome (two trisomy 21 and one unbalanced translocation, t[14;21]), and one trisomy 18. The offspring of the 23 patients in which amniocentesis was declined were phenotypically normal. CONCLUSIONS In our prospective study the risk of chromosomal abnormality with isolated choroid plexus cyst(s) was 1:25, a risk that exceeds the 1:200 risk of pregnancy loss after amniocentesis and the 1:126 and 1:260 risk for aneuploidy and Down syndrome, respectively, in a 35-year-old pregnant women during the midtrimester. These findings indicate that amniocentesis should be offered to pregnant women in the presence of isolated fetal choroid plexus cyst(s).

Isolated hyperechoic fetal bowel: significance and implications for management.

OBJECTIVE The objective of this study was to determine the significance of isolated hyperechoic fetal bowel. STUDY DESIGN Forty-five cases with prospective, ultrasonographic diagnosis of isolated hyperechoic fetal bowel were reviewed. Fetal variables, including aneuploidy, deoxyribonucleic acid studies for cystic fibrosis, congenital infection, growth retardation, and intrauterine death were reported. RESULTS Thirty-four of the 45 cases (76%) resulted in live-born infants without detected abnormalities. However, hyperechoic bowel was associated with cystic fibrosis in two cases (4%), congenital infection in two cases (4%), and fetal alcohol syndrome in one case. Termination of pregnancy was elected in three cases and intrauterine fetal death occurred in three cases (7%). Growth retardation was observed in five of 39 (13%) live-born infants. CONCLUSION Isolated hyperechoic fetal bowel is associated with significant pathologic disorders. Women whose fetuses are diagnosed as having isolated hyperechoic bowel should be offered additional prenatal diagnostic options, including maternal serologic studies for congenital infection, fetal karyotype, and deoxyribonucleic acid testing for cystic fibrosis. In addition, continuing ultrasonographic evaluation of fetal growth and antenatal biophysical assessment should be considered.

Immunoreactive tumor necrosis factor-α is elevated in maternal plasma but undetected in amniotic fluid in the second trimester

OBJECTIVE We investigated the participation of the cellular arm of the immune system in adaptation to pregnancy by assessing plasma and amniotic fluid levels of the cytokine tumor necrosis factor-alpha. STUDY DESIGN Fifty-five healthy pregnant women who underwent second-trimester genetic amniocentesis at a mean gestational age of 17.0 +/- 1.4 weeks composed study group A. Blood was drawn from each patient before amniocentesis, and an aliquot of amniotic fluid was obtained for this study. Twenty-one healthy patients at a mean gestational age of 35.5 +/- 4.8 weeks composed study group B, and blood was obtained from each patient at an outpatient prenatal visit. Twenty-two healthy, nonpregnant women of reproductive age composed the control group (C). All specimens were stored at -70 degrees C and collectively assayed for tumor necrosis factor-alpha by a specific enzyme-linked immunoassay. RESULTS All patients in group A had a normal karyotype and all patients in groups A and B had uneventful pregnancies. Tumor necrosis factor-alpha was detected in the plasma of 43 of 55 (78.2%) patients in group A compared with 7 of 21 (33.3%) patients in group B (p < 0.001); tumor necrosis factor-alpha was not detected in any of the 22 women in group C. The median plasma tumor necrosis factor-alpha level for group A was 135 pg/ml (range 0 to 625 pg/ml) compared with 0 pg/ml (range 0 to 110 pg/ml) in group B (p < 0.001). Tumor necrosis factor-alpha was not detected in any of the amniotic fluid specimens studied. CONCLUSIONS Levels of tumor necrosis factor-alpha were elevated in the plasma but not detected in the amniotic fluid of normal pregnant patients in the second trimester. These findings suggest involvement of the cellular branch of the immune system and its products, the cytokines, in the normal adaptation of the mother to the fetal allograft, with a possible role in regulating trophoblast growth and invasion.

Diabetic macrosomia: accuracy of third trimester ultrasound.

Sonar biparietal diameter, head circumference, and abdominal circumference percentile values obtained late in the third trimester were compared with birth weight percentile (relative to dates) in 147 diabetic mothers and 40 control fetuses of nondiabetics. Estimates of fetal weight by the method of Shepard et al were also calculated from these sonar data and compared with birth weight percentile. Abdominal circumference values greater than the 90th percentile correctly predicted macrosomia (defined as birth weight greater than 90th percentile) in 78% of cases. Biparietal diameter and head circumference percentiles were significantly less predictive of macrosomia. When analyzed in a similar manner, estimated fetal weights greater than the 90th percentile correctly predicted macrosomia at birth in 74% of cases. However, when both the abdominal circumference and the estimated fetal weight exceeded the 90th percentile, macrosomia was correctly diagnosed in 88.8% of pregnant women with diabetes mellitus.