Fetal anemia as a consequence of hemorrhage into an ovarian cyst.

Fetal ovarian cysts are usually benign in nature and resolve spontaneously. Complications such as torsion and rupture have been described previously. A case of presumptive spontaneous hemorrhage into a fetal ovarian cyst is presented. Serial ultrasound and Doppler assessments revealed the development of fetal anemia, which was managed by intrauterine blood transfusion.     

First-trimester uterine artery resistance and maternal serum concentration of asymmetric dimethylarginine.

OBJECTIVE: Maternal serum levels of asymmetric dimethyl-arginine (ADMA), an endogenous inhibitor of endothelial nitric oxide synthase, are known to be increased in pregnant women with high-resistance placental circulation in the second trimester. The aim of the present study was to investigate the relationship between uterine artery resistance and maternal serum ADMA concentrations in the first trimester. METHODS: Doppler ultrasound examination of the maternal uterine arteries was performed at 10-14 weeks' gestation. High resistance was defined as bilateral uterine artery notches and a mean resistance index > 95th centile. Control cases were defined as those presenting with no notches and a mean resistance index < 95th centile. ADMA concentrations were measured in maternal serum. RESULTS: Forty singleton pregnancies were examined, 21 with high uterine artery resistance and 19 controls. Three cases of pre-eclampsia occurred, all in the high-resistance group. The mean (SD) maternal serum ADMA concentration was 0.78 (44%) and 0.93 (56%) micromol/L in the high-resistance and control groups, respectively (P = 0.17). There was no statistically significant correlation between maternal serum ADMA and uterine artery resistance index (rho = - 0.15, P = 0.36). CONCLUSIONS: No significant difference was found in maternal serum ADMA between pregnancies with first-trimester high-resistance uterine artery blood flow and controls. While second-trimester circulating ADMA may have a direct link with maternal endothelial function, in the first trimester the effect of ADMA may be mainly evident at the placental level, without consequently affecting maternal circulating concentrations of the substance.     

Limitations of using first-trimester nuchal translucency measurement in routine screening for major congenital heart defects.

OBJECTIVE: To evaluate the effectiveness of nuchal translucency (NT) measurement in screening for major congenital heart disease (CHD) in chromosomally normal fetuses. DESIGN: A population based cohort study of all women having fetal NT measurement at 10-14 weeks of gestation in an unselected population over a 3-year period. The outcome measure was the identification of major CHD in chromosomally normal pregnancies either antenatally or postnatally. RESULTS: Major defects of the heart and great arteries were identified in 26 out of 7339 pregnancies (prevalence 3.5 per 1000 pregnancies). Out of 26 cases, only four (sensitivity 15.4%, 95% CI 4-35) were in the group of 258 pregnancies (3.5%) with increased NT of > or = 2.5 mm. The prevalence of major CHD increased from 3.1 per 1000 for NT < 2.5 mm to 50 per 1000 for NT > or = 3.5 mm (likelihood ratio of 14.1, 95% CI 4.2-47.9). The positive and negative predictive values for NT > or = 2.5 mm were 1.6% and 99.7%, respectively. CONCLUSIONS: The prevalence of major CHD in this study was 3.5 per 1000, suggesting that ascertainment of CHD in our study population was thorough. Fetuses with NT measurements > or = 3.5 mm have a significantly increased risk of major CHD, and this identifies a subgroup of high-risk patients in whom early fetal echocardiography would be advocated. The low sensitivity of NT for major CHD in the general population, however, indicates that NT cannot be relied on as the sole or major screening tool for this condition as previously reported.     

Maternal and neonatal outcome after failed ventouse delivery: comparison of forceps versus cesarean section.

OBJECTIVES: To compare the immediate maternal and neonatal morbidity in women delivered by forceps or cesarean section after failed ventouse delivery. METHODS: Case notes of 400 consecutive successful ventouse deliveries compared with 342 failed ventouse deliveries, where delivery was subsequently achieved with either forceps (N = 247) or cesarean section (N = 95), which took place between October 1999 and May 2003, were reviewed. RESULTS: Failed ventouse delivery was associated with an increased chance for fetal malposition (OR 3.7, 95% CI 2.6 - 5.3) and postpartum hemorrhage (OR 3.5, 95% CI 1.8 - 6.8). Compared to forceps after failed ventouse, cesarean section was associated with a higher prevalence of postpartum hemorrhage (OR 7.8, 95% CI 3.6 - 16.9) and fewer third degree perineal tears (p < 0.05). There were no significant differences between cesarean section and forceps delivery after failed ventouse for neonatal morbidity. CONCLUSIONS: Failure of ventouse delivery is 3 - 4 times more likely with a fetal malposition and is associated with an increased risk of postpartum hemorrhage. While cesarean section increases the postpartum hemorrhage rate, forceps delivery is associated with increased likelihood of third degree perineal tears. The neonatal morbidity was comparable regardless of whether forceps or cesarean was used after failed ventouse.     

Natural history and outcome of prenatally diagnosed cystic hygroma

OBJECTIVE: To define the outcome in cases of cystic hygroma diagnosed from a routine obstetric population. METHOD: This was a retrospective study of 42 cases of fetal cystic hygroma detected at 11 to 23 weeks' gestation in a routine obstetric population of 25 352 pregnancies. Fetal cystic hygroma was categorized according to position, severity, presence of cardiac defects and Hydrops fetalis. RESULTS: There were 20 (47.6%) cases with aneuploidy (9 trisomies and 11 Turner's syndrome). Major congenital cardiac defects were identified in 12 (28.6%) cases. Regression of the hygroma was noted in 2/20 (10%) of the aneuploid pregnancies and 3/17 (17.6%) of the euploid pregnancies. The majority (90.0%) of the aneuploid fetuses were female. In contrast, 70.58% of the fetuses in the euploid group were male and all the surviving normal babies were also male (n = 3). CONCLUSION: The findings of this study would support invasive prenatal diagnosis for an ultrasound finding of fetal cystic hygroma. Even in euploid pregnancies with cystic hygroma, there is a high mortality with associated abnormalities. The data also suggest a guarded pregnancy prognosis for the finding of fetal cystic hygroma, and that it is improved with spontaneous resolution, especially in male fetuses of normal karyotype.     

Maternal ethnic origin and fetal nasal bones at 11-14 weeks of gestation

Objectives   Failure to visualise the fetal nasal bones at 11–14 weeks of gestation is associated with a significant increase in the risk for trisomy 21. However, it is not known whether the ethnic origin of the mother has any effect on the fetal profile and the prevalence of this marker.
Design   Prospective study.
Setting   London Teaching Hospital.
Population   Four thousand and four hundred and ninety-two consecutive fetuses undergoing routine first trimester ultrasound scanning at 11–14 weeks of gestation in a multiethnic population.
Methods   Examination of the nasal bones was attempted in the fetuses.
Main outcome measure   Rate of visualisation of the fetal nasal bones.
Results   Five hundred fetuses were excluded from the analysis because of chromosomal abnormalities or a technically unsatisfactory examination. In the remaining 3992 fetuses, the maternal ethnic origin was African in 13.0%, Asian in 15.3% and Caucasian in 66.0%. Compared with Caucasians, the failure to visualise the fetal nasal bones was significantly higher in women of African ( P = 0.0001) but not Asian origin ( P = 0.24). A multivariable logistic regression model showed that having a mother of African origin is still significantly associated with an increased likelihood of absent fetal nasal bones compared with Caucasians (odds ratio 2.33), even after correcting for maternal age, parity and crown–rump length.
Conclusion   There is a significant difference in the rate of visualisation of the fetal nasal bones in the first trimester in mothers of different ethnic origin. This suggest that corrections for maternal ethnicity will be required to ensure equity of fetal nasal bone screening in multiracial populations. Whether corrections are required for the father's ethnic origin remains to be determined.     

The anatomy of the umbilical, portal and hepatic venous systems in the human fetus at 14-19 weeks of gestation.

BACKGROUND: Ultrasound imaging of the fetal ductus venosus is becoming increasingly commonplace in clinical practice. The true anatomical relationships of the fetal umbilical and portal venous systems have not been clearly defined due to paucity of published data on the relevant anatomy. This has led to confusing terminology when describing the fetal umbilical, portal and hepatic circulations. The aim of the present study was to examine and document the anatomy of the umbilical, portal and hepatic venous systems and to propose a standardized nomenclature. METHODS: This was a prospective study on 11 fetuses obtained from medical termination of pregnancies between 14 and 19 weeks of gestation. The liver was microdissected to expose the branching pattern and anatomical relations of the umbilical, portal and hepatic venous systems. RESULTS: A wide L-shaped venous confluence at the terminal end of the umbilical vein, termed the portal sinus, was identified. The portal sinus was connected to the right and left hepatic lobes, by the right and left intrahepatic portal veins, respectively. The extrahepatic portal vein drained into the portal sinus just before the origin of the right intrahepatic portal vein. The ductus venosus, a branchless straight vessel, originated from the portal sinus and ascended steeply in the direction of the diaphragm. Numerous small vessels draining the liver converged into three main hepatic veins, which open into the subdiaphragmatic vestibulum. CONCLUSION: Based on detailed sequential anatomical dissection and clear illustrations, the present study documents the anatomy of the umbilical, portal and hepatic venous systems. Taking into account the embryological origin of the vessels, a new anatomically appropriate and simplified nomenclature of these venous systems is proposed. In clinical practice, the consistent use of the suggested terminology would allow collection of comparable data between units and enable operators to be confident of which vessels they are sampling by Doppler ultrasound.     

Fetal and maternal erythropoietin levels in normal pregnancy.

In a cross-sectional study of 120 pregnancies undergoing cordocentesis for prenatal diagnosis (n = 90) or elective caesarean section (n = 30), the umbilical cord and maternal venous plasma erythropoietin (Epo) concentrations were measured. Fetal Epo levels increased from a mean of 4 mU/ml at 16 weeks to 13 mU/ml at 40 weeks' gestation. There were no significant associations between fetal plasma Epo concentration and fetal blood gases, haemoglobin concentration, oxygen content or erythroblast count. The maternal plasma Epo concentration (mean = 14 mU/ml, range 1-77 mU/ml) did not change with gestation but was significantly higher than levels in non-pregnant females (mean = 6.6 mU/ml, range 1-25 mU/ml).     

A newly described thoracic vascular malformation in fetuses with Down syndrome.

OBJECTIVES: To report the association between thoracic vascular malformations observed in the first trimester of pregnancy and Down syndrome. METHODS: The clinical features were reviewed of seven fetuses undergoing chorionic villus sampling (CVS) for increased nuchal translucency (NT) thickness, in which color Doppler ultrasonography revealed a vascular malformation in the fetal thorax. RESULTS: The crown-rump length of the fetuses ranged from 58 to 78 mm and NT measurements ranged from 2.9 to 10.0 mm. Color Doppler allowed the identification of a highly vascular structure in the posterolateral portion of the fetal thorax, in proximity to the costovertebral angle, at the level of a four-chamber view of the heart. The lesions had a globular shape and were 4-6 mm in diameter, occupying almost one third of the hemithorax. Down syndrome was diagnosed in five out of the seven cases. In the only affected case that underwent postmortem examination, a hemangioma of the chest wall was demonstrated. In the two fetuses with normal karyotype, the lesion disappeared by mid-gestation. CONCLUSION: We report an association between the prenatal Doppler finding of a vascular tumor in the fetal chest and Down syndrome.