Seizo Miyadahira

Prognostic factors associated with congenital cystic adenomatoid malformation of the lung

This study presents 18 cases of prenatally diagnosed congenital cystic adenomatoid malformation (CCAM) to identify potential factors that could predict prognosis. Comparisons of prenatal parameters were made between fetuses that survived and those that died perinatally. It was found that microcystic lesion, bilateral lung involvement and hydrops were each highly correlated with poor prognosis, while neither polyhydramnios nor mediastinal shift was significantly associated with had outcome. Fetal interventions were indicated only in two of the surviving cases: a thoracocentesis and a cysto‐amniotic shunt. A therapeutic amniocentesis was performed in one case of polyhydramnios. The diagnosis of CCAM was histologically confirmed in all cases by necropsy or by postnatal lobectomy. Copyright

Elevation of Uterine Basal Tone and Fetal Heart Rate Abnormalities After Labor Analgesia A Randomized Controlled Trial

OBJECTIVE: To estimate the effects of combined spinal–epidural and traditional epidural analgesia on uterine basal tone and its association with the occurrence of fetal heart rate (FHR) abnormalities. METHODS: Seventy-seven laboring patients who requested pain relief during labor were randomly assigned to combined spinal–epidural (n=41) or epidural analgesia (n=36). Uterine contractions and FHR were recorded 15 minutes before and after analgesia. Uterine tone was evaluated with intrauterine pressure catheter. Primary outcomes were the elevation of baseline uterine tone and occurrence of FHR prolonged decelerations or bradycardia after analgesia. The influence of other variables such as oxytocin use, hypotension, and speed of pain relief were estimated using a logistic regression model. RESULTS: The incidence of all outcomes was significantly greater in the combined spinal–epidural group compared with epidural: uterine hypertonus (17 compared with 6; P=.018), FHR abnormalities (13 compared with 2; P<.01), and both events simultaneously (11 compared with 1; P<.01). Logistic regression analysis showed the type of analgesia as the only independent predictor of uterine hypertonus (odds ratio 3.526, 95% confidence interval 1.21–10.36; P=.022). For the occurrence of FHR abnormalities, elevation of uterine tone was the independent predictor (odds ratio 18.624, 95% confidence interval 4.46–77.72; P<.001). Regression analysis also found a correlation between decrease on pain scores immediately after analgesia and the estimated probability of occurrence of hypertonus and FHR abnormalities. CONCLUSION: Combined spinal–epidural analgesia is associated with a significantly greater incidence of FHR abnormalities related to uterine hypertonus compared with epidural analgesia. The faster the pain relief after analgesia, the higher the probability of uterine hypertonus and FHR changes. CLINICAL TRIAL REGISTRATION: Umin Clinical Trials Registry, http://www.umin.ac.jp/ctr/index.htm, UMIN000001186 LEVEL OF EVIDENCE: I

Predicting pH at birth in absent or reversed end-diastolic velocity in the umbilical arteries.

OBJECTIVE: To investigate arterial and venous blood flow in fetuses with absent or reversed end-diastolic flow in the umbilical arteries and to correlate the Doppler results with umbilical artery blood pH at birth to predict the probability of acidosis at birth. METHODS: Ninety-one fetuses from singleton pregnancies without fetal malformations with a diagnosis of absent or reversed end-diastolic flow in the umbilical arteries were prospectively studied. On the day of delivery, Doppler velocimetry of the umbilical arteries, middle cerebral artery, and ductus venosus was performed and the results were correlated with umbilical artery pH at birth at the following cutoff levels: pH < 7.20, < 7.15, < 7.10, and < 7.05. The association between fetal arterial and venous Doppler velocimetry and acidosis was then individually analyzed by the &khgr;2 and Fisher exact tests. The ability of these tests to predict the probability of acidosis at birth was estimated using a logistic regression model. RESULTS: There was a negative correlation between pH at birth and umbilical artery pulsatility index (r = –0.39; P < .001) and pulsatility index for veins in the ductus venosus (r = –0.63; P < .001). Assessment of the fetal arterial circulation (middle cerebral artery) showed no statistical correlation with pH at birth. Using logistic regression analysis, probability curves were constructed for pH values less than 7.20 (odds ratio [OR] 8.03), less than 7.15 (OR 11.92), less than 7.10 (OR 12.16), and less than 7.05 (OR 8.20). CONCLUSION: The pulsatility index for veins of the ductus venosus was related to pH at birth, demonstrating that the higher the ductus venosus pulsatility index for veins, the lower the pH at birth. Once the pulsatility index for veins in the ductus venosus is known, the probability of acidosis at birth can be estimated. LEVEL OF EVIDENCE: II-2

Fetal hemodynamic changes following maternal betamethasone administration in pregnancies with fetal growth restriction and absent end-diastolic flow in the umbilical artery

Objectives. To examine the effects of betamethasone administration on umbilical artery (UA), middle cerebral artery (MCA) and ductus venosus (DV) Doppler flow. Design. Longitudinal prospective study. Setting: Fetal Surveillance Unit, Department of Obstetrics and Gynecology, University of São Paulo, São Paulo, Brazil. Population. Thirty‐two singleton pregnancies complicated by fetal growth restriction with absent end‐diastolic flow in the UA. Methods. Pulsatility index (PI) of the UA, MCA and DV was measured from 26 to 34 weeks prior to and within 24 or 48 hours after starting betamethasone treatment course. Analysis of variance for repeated measures was used to determine the changes in the fetal hemodynamic Doppler flow following maternal corticosteroid administration. Main outcome measures. Improvement of UA‐PI within 24 hours and DV‐PIV (venous pulsatility) within 48 hours from the first betamethasone dose. Results. Mean gestational age at delivery was 29.3 (±1.8) weeks and birthweight was 806.6 (±228.2) g. A reduction in the UA‐PI was observed in 29 (90.6%) cases, with return of end‐diastolic flow in 22 (68.7%). The mean UA‐PI were 2.84 (±0.52) before corticosteroid administration, 2.07 (±0.56) within 24 hours and 2.42 (±0.75) after 48 hours, with a significant difference along the evaluations (p<0.001). No significant changes in the MCA Doppler were observed. DV‐PIV decreased from 1.06 (±0.23) prior corticosteroids administration to 0.73 (±0.16) within 24 hours and 0.70 (±0.19) after 48 hours (p<0.001). Conclusions. There was reduction in the umbilical artery and in the DV pulsatility indices within 24 hours from betamethasone administration that was maintained up to 48 hours.

Fetal renal biopsies in obstructive uropathy: feasibility and clinical correlations—preliminary results

Final assessment on the outcome of fetal obstructive uropathy is a challenging matter. Ultrasonography, fetal urine electrolytes, and beta 2 microglobulin are postulated as being useful in many cases. For cases in which renal function remains unclear, ultrasound‐guided fetal kidney biopsy may be used in order to detect histologic features distinctive of renal dysplasia. We present preliminary results aimed at studying the feasibility and possible risks. Biopsies were initially performed in 11 severely malformed fetuses, three of them with associated renal abnormalities. The success rate in obtaining renal material was 63·6 per cent with no maternal complications. In the next phase of this study, ten biopsies and urine collections were performed in fetuses with bilateral obstructive uropathy. The success rate was 50 per cent with no complications. Normal fetal renal histology was seen in 80 per cent of cases. In one case, although electrolytes were normal, a histologic diagnosis of renal dysplasia was made, showing a good correlation with outcome. In conclusion, fetal kidney biopsies for obstructive uropathy are feasible and further studies are needed to show their clinical relevance and risks.

Cardiac troponin T as a biochemical marker of cardiac dysfunction and ductus venosus Doppler velocimetry

OBJECTIVES The aim of this study was to determine the correlation between ductus venosus (DV) Doppler velocimetry and fetal cardiac troponin T (cTnT). STUDY DESIGN Between March 2007 and March 2008, 89 high-risk pregnancies were prospectively studied. All patients delivered by cesarean section and the Doppler exams were performed on the same day. Multiple regression included the following variables: maternal age, parity, hypertension, diabetes, gestational age at delivery, umbilical artery (UA) S/D ratio, diagnosis of absent or reversed end-diastolic flow velocity (AREDV) in the UA, middle cerebral artery (MCA) pulsatility index (PI), and DV pulsatility index for veins (PIV). Immediately after delivery, UA blood samples were obtained for the measurement of pH and cTnT levels. Statistical analysis included the Kruskal-Wallis test and multiple regressions. RESULTS The results showed a cTnT concentration at birth >0.05 ng/ml in nine (81.8%) of AREDV cases, a proportion significantly higher than that observed in normal UA S/D ratio and UA S/D ratio >p95 with positive diastolic blood flow (7.7 and 23.1%, respectively, p<0.001). A positive correlation was found between abnormal DV-PIV and elevated cTnT levels in the UA. Multiple regression identified DV-PIV and a diagnosis of AREDV as independent factors associated with abnormal fetal cTnT levels (p<0.0001, F(2.86)=63.5, R=0.7722). CONCLUSION DV-PIV was significantly correlated with fetal cTnT concentrations at delivery. AREDV and abnormal DV flow represent severe cardiac compromise, with increased systemic venous pressure, and a rise in right ventricular afterload, demonstrated by myocardial damage and elevated fetal cTnT.

Ductus venosus Doppler and postnatal outcomes in fetuses with absent or reversed end-diastolic flow in the umbilical arteries.

OBJECTIVE To evaluate the relationship between ductus venosus Doppler findings on the day of delivery and postnatal outcomes in pregnancies with absent or reversed end-diastolic (ARED) flow in the umbilical arteries. STUDY DESIGN Postnatal outcomes of 103 newborns of pregnancies with a diagnosis of ARED flow on Doppler velocimetry of the umbilical arteries were analyzed retrospectively between January 1997 and December 2004. Single pregnancies and fetuses without malformations were included. The cases were divided into two groups according to the flow during atrial contraction (a-wave) in the ductus venosus on the day of delivery: group A, 20 cases with absent or reversed flow in the ductus venosus and group B, 83 cases with positive flow. The results were analyzed statistically using the chi-square test, Fishers exact test and the Mann-Whitney U test with the level of significance set at 5%. RESULTS All newborns were delivered by cesarean section. Gestational age was similar in the two groups (group A: 30 weeks and group B: 30.9 weeks, P=0.23). Absent or reversed ductus venosus flow was associated with the following adverse postnatal outcomes: lower birthweight (P<0.001), lower Apgar scores in the first (P=0.001) and fifth minute (P=0.001), a higher frequency of orotracheal intubation (P=0.001) and pH at birth less than 7.20 (P<0.001), pulmonary hemorrhage (P=0.03), thrombocytopenia (P=0.02), hypoglycemia (P=0.01), intracranial hemorrhage (P=0.02), and postnatal death (P=0.007). CONCLUSION The study of ductus venosus flow may provide additional information regarding the best time for interruption of pregnancies with ARED flow in the umbilical arteries characterized by extreme prematurity.

Fetal venous Doppler in pregnancies with placental dysfunction and correlation with pH at birth

Objectives: To determine the correlation between ph at birth and venous Doppler parameters in pregnancies with placental dysfunction. Methods: This was a prospective cohort study of 58 pregnancies with the diagnosis of placental dysfunction between 26 and 34 weeks of gestation. Inclusion criteria were singleton pregnancies, abnormal umbilical artery (UA) Doppler, fetal growth restriction diagnosed by estimated fetal weight <10th centile for gestational age, intact membranes, and absence of fetal congenital abnormalities. The Doppler measurements were the following: UA pulsatility index (PI), ductus venosus (DV) pulsatility index for veins (PIV), intra-abdominal umbilical vein (UV) time-averaged maximum velocity (TAMxV) and blood flow and left portal vein (LPV) time-averaged maximum velocity (TAMxV) and blood flow. All Doppler parameters were transformed into z-scores (SD values from the mean) according to normative references. Results: The UA pH at birth showed a negative significant correlation with the DV-PIV (p = 0.004) and the DV-PIV z-score (p = 0.004), while LPV TAMxV (p = 0.004), LPV TAMxV z-score (p = 0.002), LPV blood flow (p = 0.01), LPV blood flow normalized (p = 0.04) and UV blood flow (p = 0.04) positively correlated with pH at birth. Multiple regression analysis was performed and the DV-PIV z-score was the variable that independently correlated with pH at birth (p = 0.002). Conclusions: the present results suggest that changes in fetal venous blood flow, mainly DV and LPV are useful in the management of cases with early onset placental insufficiency and that venous Doppler parameters correlate with pH at birth.

Avaliação da vitalidade fetal e resultados perinatais em gestações após gastroplastia com derivação em Y de Roux

OBJETIVO: Analisar os resultados da avaliacao da vitalidade fetal de gestacoes apos gastroplastia com derivacao em Y de Roux, verificando as complicacoes maternas e os resultados perinatais. METODOS: No periodo de julho de 2001 a setembro de 2009, foram analisados, retrospectivamente, dados de prontuario de pacientes com gestacao apos gastroplastia com derivacao em Y de Roux, acompanhadas em pre-natal especializado e cujo parto foi realizado na instituicao. Foram analisados os exames de avaliacao da vitalidade fetal (cardiotocografia, perfil biofisico fetal e dopplervelocimetria das arterias umbilicais) realizada na semana anterior ao parto. As variaveis maternas investigadas foram: dados demograficos, complicacoes clinicas maternas, tipo de parto, complicacoes no parto e pos-parto, exames hematimetricos maternos e resultados perinatais. RESULTADOS: Trinta gestacoes apos gastroplastia com derivacao em Y de Roux foram identificadas e 24 delas foram submetidas a avaliacao da vitalidade fetal. Todas as pacientes apresentaram resultados normais na cardiotocografia, no perfil biofisico fetal e na dopplervelocimetria das arterias umbilicais. Houve um caso de oligohidrâmnio. A principal complicacao observada foi anemia materna (Hb < 11,0 g/dL, 86,7%). A cesarea foi realizada em 21 pacientes (70%). As complicacoes do parto incluiram um caso de aderencias, um de hematoma e infeccao de parede e um de histerectomia pos-parto por miomatose e atonia uterina. A proporcao de recem-nascidos pequenos para a idade gestacional foi de 23,3%. CONCLUSAO: Nao houve comprometimento do bem-estar fetal em gestacoes apos gastroplastia com derivacao em Y de Roux. A principal complicacao materna foi a anemia e essas mulheres requerem aconselhamento nutricional especifico com ampla avaliacao das deficiencias de micronutrientes desde o inicio da gravidez.

Avaliação da Vitalidade Fetal em Gestantes Diabéticas: Análise dos Resultados Neonatais

Purpose: to study the fetal well-being assessment in pregnancies complicated by diabetes, and to analyze the neonatal results. Methods: we studied 387 pregnant women with diabetes at the Fetal Surveillance Unit. The last examination (cardiotocography, fetal biophysical profile, amniotic fluid index and dopplervelocimetry) was correlated with the neonatal outcome. Results: the studied population included 46 (12%) type I diabetes, 45 (12%) type II and 296 (76%) gestational diabetes. Type I diabetes with abnormal or suspected cardiotocography was related to abnormal 1st minute Apgar (50 and 75%, p<0.05) and to the need for neonatal intensive care unit (50 and 75%, p<0.05). The abnormal biophysical profile in type II diabetic pregnancy was related to the need for neonatal intensive care (67%, p<0.05), and abnormal umbilical artery Doppler study was related to abnormal 1st minute Apgar (67%, p<0.05). Gestational diabetes with abnormal cardiotocography presented 36% abnormal 1st minute Apgar (p<0.05), 18% abnormal 5th minute Apgar (p<0.01) and 18% neonatal death (p<0.01). Abnormal amniotic fluid index was related to abnormal 5th minute Apgar (p<0.05) and need for neonatal intensive care unit (p<0.05). Gestational diabetes with abnormal umbilical artery Doppler was related (p<0.05) to: abnormal 1st and 5th minute Apgar, respectively, 25 and 8%, Need for neonatal intensive care in 17% and neonatal death in 8%. Conclusions: the fetal well-being examinations correlated with adverse perinatal outcome, showing the need for fetal surveillance in diabetic pregnant women.