Ronald M. Ramus

Persistence of placenta Previa according to Gestational age at ultrasound detection

OBJECTIVE To evaluate gestational age at ultrasound detection of placenta previa as a predictor of previa persistence until delivery, and to estimate the effects of previa type, parity, and prior cesarean delivery on previa persistence. METHODS This was a retrospective cohort study of pregnancies with placenta previa detected during transabdominal or endovaginal ultrasound examination. Previa was categorized as complete if the placenta completely covered the internal cervical os or incomplete if the inferior placental edge partially covered or reached the margin of the os. Gestational age was grouped into 4‐week intervals from 15 to 36 weeks. The outcome was cesarean delivery for persistent previa. RESULTS Previa was detected during 940 ultrasound examinations in 714 pregnancies. Of those with placenta previa at 15–19 weeks, 20–23 weeks, 24–27 weeks, 28–31 weeks, and 32–35 weeks, previa persisted until delivery in 12%, 34%, 49%, 62%, and 73%, respectively. At each interval, complete previa was more likely to persist than incomplete previa, all P < .001. Prior cesarean delivery was an independent risk factor for persistent previa among women diagnosed with previa in the second trimester, P < .05. However, parity was not an independent risk factor for persistence at any gestational age interval after adjusting for prior cesarean delivery. CONCLUSION Gestational age at ultrasound detection of placenta previa may be used to predict likelihood of previa persistence. After midpregnancy, risk of persistence appears to be higher than previously reported. Type of placentation and prior cesarean delivery are important factors that modify the risk that previa will complicate delivery.

Hydramnios: Anomaly prevalence and sonographic detection

OBJECTIVE To characterize the prevalence and ultrasound detection of fetal anomalies in pregnancies with hydramnios, and to estimate anomaly and aneuploidy risks when no sonographic abnormality is noted. METHODS This was a retrospective cohort study of singleton pregnancies with hydramnios. Hydramnios was categorized as mild, moderate, or severe based on greatest amniotic fluid index of 25.0–29.9 cm, 30.0–34.9 cm, or 35.0 cm or more, respectively. Antenatal anomaly detection was compared with assessment in the immediate neonatal period. Aneuploidy and fetal deaths were analyzed separately. RESULTS Hydramnios was diagnosed in 672 pregnancies, and 77 (11%) of neonates had one or more anomalies. Though more severe hydramnios was associated with higher likelihood of anomaly (P < .001), sonographic anomaly detection (79%) did not differ according to degree of hydramnios (P = .4). Of anomalies which eluded sonographic diagnosis, cardiac septal defects, cleft palate, imperforate anus, and tracheoesophageal fistula were the most frequent. If sonographic evaluation was normal, the risk of a major anomaly was 1% with mild hydramnios, 2% with moderate hydramnios, and 11% with severe hydramnios (P < .001). Aneuploidy was present in 10% of fetuses with sonographic anomalies and 1% without apparent sonographic anomalies. The fetal death rate was 4% in the setting of hydramnios; 60% of these cases had anomalies. CONCLUSION The anomaly detection rate in pregnancies with hydramnios was nearly 80%, irrespective of the degree of amniotic fluid increase. Residual anomaly risk after normal sonographic evaluation was 2% or less if hydramnios was mild or moderate and 11% if severe.

Risk of Hepatitis B Transmission After Amniocentesis in Chronic Hepatitis B Carriers

OBJECTIVE: To measure the risk of perinatal transmission of HBV in chronic carriers who undergo amniocentesis. METHODS: This was a prospective, longitudinal study from 1990 to 1995 of women who were HBV carriers and underwent amniocentesis. The infants of these women were followed from birth to one year of age. Maternal data examined included HBV antigen and antibody status, liver function tests (LFTs) and the amniocentesis report. RESULTS: Twenty-eight women were identified. Two of 28 neonates were stillborn unrelated to hepatitis. Five infants were lost to follow-up leaving 21 mother-child pairs to evaluate. All 21 women were chronic HBV carriers at the time of amniocentesis for delivery. No mother had abnormal LFTs, and only one of 21 women was positive for hepatitis B e antigen (HBeAg). Thirteen amniocenteses were for advanced maternal age, and four were for abnormal maternal serum alphafetoprotein (MSAFP) screening. None of the amniocenteses were recorded as bloody, and the placenta was anterior in 6 of 21 procedures. None of the 21 infants (95% CI: 0-16.8%) were positive for HbsAg during the first month of life or at 12 months of age. All infants received HBV vaccine and HBIG immunoprophylaxis. CONCLUSION: The risk of transmission of HBV to the fetus after amniocentesis in women who are HBV carriers is low. Immunoprophylaxis in these infants was successful.

Ultrasonographic prediction of fetal outcome in suspected skeletal dysplasias with use of the femur length–to–abdominal circumference ratio☆☆☆★

OBJECTIVE Our purpose was to determine whether the femur length-to-abdominal circumference ratio can be used antenatally to predict a lethal skeletal dysplasia. STUDY DESIGN All obstetric sonograms performed from January 1990 to October 1995 were reviewed (44,020 studies) to find those scans suggestive of a skeletal dysplasia. Thirty patients were identified. The femur length/abdominal circumference ratio was then calculated from each patients initial and subsequent sonograms. Birth outcomes were obtained on the 27 patients who elected to continue their pregnancies. RESULTS All fetuses with a lethal skeletal dysplasia (n = 12) had a ratio <0.16. The fetuses with a nonlethal dysplasia (n = 8) had ratios between 0.134 and 0.193, with only 1 fetus with a ratio <0.16. All fetuses with no evidence of a skeletal dysplasia after birth (n = 7) had femur length/abdominal circumference ratios >0.18. The 1 fetus with a ratio <0.16 who survived the neonatal period had extreme bowing and demonstrates the limitation of the ratio when bowing is present. CONCLUSIONS A stillbirth or neonatal death occurred in 12 of 13 patients with a femur length/abdominal circumference ratio <0.16, independent of gestational age. Conversely, no fetus with a ratio >0.16 was found to have a lethal skeletal dysplasia. This information may be useful in counseling women when ultrasonography suggests the diagnosis of a skeletal dysplasia.

Early repair of episiotomy dehiscence associated with infection.

OBJECTIVE The purpose of our study was to examine early repair of episiotomy dehiscences in a large urban hospital setting serving a predominantly indigent population. STUDY DESIGN Since September 1, 1989, we have proceeded with early repair in the immediate postpartum period. The medical records of 34 of 35 patients who underwent early repair were reviewed. RESULTS Of the 34 patients, 21 (62%) had midline and 13 (38%) had mediolateral episiotomies. Dehiscence was associated with episiotomy infection in 27 (79%) of the 34 patients: 18 (86%) in the midline group and 9 (69%) in the mediolateral group. Repair was accomplished from 3 to 13 days (mean = 6.4) after dehiscence. Successful repairs were accomplished in 32 (94%) of 34 patients. Two (6%) patients with initial third-degree episiotomies had a subsequent breakdown of their repairs and were allowed to heal by secondary intention. CONCLUSIONS Although most dehiscences in our population were associated with infection, early repair in this population is associated with a satisfactory outcome in the vast majority.

Outcome of twin gestations with a single anomalous fetus

OBJECTIVE Our goal was to determine whether the presence of one anomalous fetus in a twin gestation affects pregnancy outcome when compared with twin pregnancies without fetal anomalies. STUDY DESIGN Maternal and neonatal data from 970 twin pregnancies delivered from 1988 to 1995 were collected. Three groups of twin gestations were identified: one fetus with a major anomaly (n = 18), one fetus with a minor anomaly (n = 38), and both fetuses without anomalies (n = 914). RESULTS Maternal demographic characteristics (age, race, and antepartum complications) were similar among the groups. There was no difference in neonatal outcome (gestational age at delivery, birth weight, cord pH, sepsis, and death) in the minor anomaly and no anomaly groups. There were significant differences between the major anomaly group and the no anomaly group in gestational age at delivery (32.9 vs 35.6 weeks, p < 0.05), birth weight at delivery (1759 vs 2291 gm, p < 0.05), hospital days (41 vs 13 days, p < 0.05), and perinatal death of the anomalous fetus (278/1000 vs 10/1000). Except for total days in the hospital, there was no difference in neonatal morbidity or mortality for the normal fetus when compared with the minor group or the no anomaly group. CONCLUSION The presence of a fetus with a major anomaly in a twin gestation increases the risk of preterm delivery. The neonatal outcome of the nonanomalous fetus does not appear to be affected by the anomalous fetus.

Extensive Brain Injury in a Premature Infant Following a Relatively Minor Maternal Motor Vehicle Accident with Airbag Deployment

Traumatic injury following a motor vehicle accident during pregnancy has an enormous potential for fetal injury and demise. With the advent of seat belts, shoulder restraints and airbags, and improved maternal survival, the most common cause of fetal loss is placental injury. However, the safety of airbag deployment during pregnancy and in particular during the latter stages, and the potential for fetal trauma remains unclear. We report a case of extensive neurological injury of a premature infant with minimal maternal trauma associated with deployment of an airbag following a minor motor vehicle accident.

Fryns syndrome: prenatal diagnosis and pathologic correlation.

The patient is a 20 year old gravida 2 para 1 Hispanicwoman who was referred for ultrasonographic eval-uation because of uterine size less than expected fordates. Her previous child is healthy. She was in anonconsanguineous relationship.Antenatal ultrasonography revealed fetal biomet-ric data consistent with a 16 week singleton gesta-tion. The amount of amniotic fluid was normal.Multiple fetal anomalies were noted, including scalpand hand edema with redundant skin and bilateralcystic hygromas extending along the spine (Fig. 1). Adiaphragmatic hernia was noted with dextropositionof the heart secondary to mass effect. The stomachwas in the fetal thorax (Fig. 2). The kidneys wereechogenic (Fig. 3). Amniocentesis was performed,which subsequently documented a normal femalekaryotype. Amniotic fluid alpha-fetoprotein levelswere normal.A follow-up ultrasonogram was obtained 3 weekslater, after the final results of the amniocentesis wereavailable. Fetal growth as assessed with biometricswas now consistent with an 18 week gestation. Againthe diaphragmatic hernia, echogenic kidneys, andcystic hygroma were noted. The amniotic fluid vol-ume was now low normal with the largest pocketmeasuring 38 mm. At this time cardiac evaluationwas performed and a small aortic outflow tract, smallleft ventricle, mediastinal shift, and ventriculoseptal

Autopsy, radiographic, and prenatal ultrasonographic examination of a stillborn fetus with femoral facial syndrome

Femoral facial syndrome (FFS) is comprised of cleft palate, micrognathia, short or absent femora, and vertebral and genitourinary malformations. We report on a stillborn fetus with FFS delivered to a mother with gestational diabetes. Prenatal ultrasound examination showed abnormalities at 21 weeks of gestation; prior ultrasound findings were interpreted as normal. Long bone histology showed disorganization of the growth plate with a relative decrease in cartilaginous matrix and vacuolization and binucleation of the chondrocytes.

Middle cerebral artery peak systolic velocity in monochorionic and dichorionic twin pregnancies

The purpose of this study was to compare middle cerebral artery (MCA) peak systolic velocity (PSV) values in monochorionic (MC) and dichorionic (DC) twin pregnancies.