- Email: [email protected]
Value of antenatal diagnosis of abnormalities of the urinary tract
92
Citations from the Literature
that a short-term infusion of magnesium sulfate leads to a sustained decline in palsma renin activity in preeclamptic wonmen, but exerts no sustained effect on angiotensin-converting enzyme in women with either preeclampsia or preterm labor. Synchronous intrauterine with clomiphene citrate
and ectopic
pregnancy
associated
Raccuia JS; Neckles S; Butler D; Kahn M; Ibrahim IM Department of Surgery, Englewood Hospital, Englewood, NJ 07062; USA Surgery Gynecology & Obstetrics/l68/5 (417-420)/1989/ Although synchronous intrauterine and ectopic pregnancies associated with the use of clomiphene citrate for infertility are rare, the actual incidence might, in fact, be considerably higher than previously thought. The cornerstone for ruling out an extrauterine gestation is the presence of sonographic evidence of an intrauterine pregnancy, as the possibility of concomitant intrauterine and extrauterine gestation is perceived to be statistically rare. This has resulted in an unacceptably high incidence of negative ultrasound interpretations. During a recent 12 month period, four women treated with clomiphene citrate for infertility were diagnosed as having concomitant intrauterine and ectopic pregnancies. Three had pelvic sonograms that were erroneous for the extrauterine component. However, successful evacuation of the products of ectopic gestation was performed in each, despite an immediate preoperative falsenegative ultrasound report. Three of the women delivered healthy normal infants at full term, and the fourth woman spontaneously aborted the products of the concomitant intrauterine gestation. All four did well postoperatively, and no gross complications were encountered. Reassessment of ultrasound diagnostic criteria and the use of more sensitive mehtods, such as endovaginal ultrasound in high risk patients, are indicated for any symptomatic patient using clomiphene citrate for infertility. Awareness of the prevalence of this entity and the limitations of ultrasound will lead to prompt intervention and improved survival rates. Inhibin: A new circulating marker of hydatidiform
mole?
Yohkaichiya T; Fukaya T; Hoshiai H; Yajima A; De Kretser DM Department of Anatomy, Monash University, Clayton, SA 3168; Australia BR MED J/298/6689 (1684--1686)/1989/ Objective - To define the concentrations of inhibin in serum and tissue of patients with hydatidiform mole and assess their value as a clinical marker of the condition. Design Prospective study of new patients with hydatidiform mole, comparison of paired observation, and case-control analysis. Setting-A university hospital, two large public hospitals, and a private women’s clinic in Japan. Patients - Seven consecutive referred patients seen over four months with newly diagnosed complete hydatidiform mole, including one in whom the mole was accompanied by viable twin fetuses (case excluded from statistical analysis because of unique clinical features). All patients followed up for six months after evacuation of molar tissue. End point - Correlation of serum inhibin conInt J Gynecol Obstet 31
centrations with trophoblastic disease. Measurements and main results - Serum concentrations of inhibin, human chorionic gonadotrophin, and follicle stimulating hormone were compared before and seven to 10 days after evacuation of the mole. Before evacuation the serum inhibin concentrations (median 8.3 U/ml; 95% confidence interval 2.4 to 34.5) were significantly greater than in 21 normal women at the same stage of pregnancy (2.8 U/ml; 2.1 to 3.6), and inhibin in molar tissue was also present in high concentrations (578 U/ml cytosol; 158 to 1162). Seven to 10 days after evacuation inhibin concentrations in serum samples from the same patients declined significantly to values (0.4 U.mI; 0.1 to 1.4) similar to those seen in the follicular phase of normal menstrual cycles. None of the four patients whose serum inhibin concentrations were 0.4 U/m1 or less after evacuation developed persistent trophohlastic disease. Though serum human chorionic gonadotrophin concentrations declined after evacuation (6.6 x lo) III/l; 0.8 x lo3 to 32.6 x lo), they remained far higher than in non-pregnant women. Serum follicle stimulating hormone concentrations remained suppressed. Conclusions - In this small study serum inhibin concentrations higher than those found in the early follicular phase one to two weeks after evacuation of a hydatidiform mole seemed to be specific for persistent trophoblastic disease. Further data are needed to confirm these promising results.
Value of antenatal tract
diagnosis
of abnormalities
of the urinary
Greig JD; Raine PAM; Young DC; Azmy AF; MacKenzie JR; Danskin F; Whittle MJ; McNay MB Department of Paediatric Surgery, Royal Hospital for Sick Children, Glasgow, G3 8SJ; United Kingdom BR MED J/298/6685 (1417-1419)/1989) Objective - To assess the value of antenatal diagnosis of abnormalities of the urinary tract on ultrasonography. Design - Retrospective study. Setting - Two obstetric units in GIasgow. Subjects - 62 Fetuses in which renal abnormalities were diagnosed on antenatal ultrasonography. Interventions - Six fetuses had their bladders aspirated to determine renal function. Fifteen pregnancies were terminated on the basis of the findings on antenatal ultrasonography, and if possible necropsy was performed on the fetuses. In babies who were born alive the final diagnosis was made by postnatal ultrasonography, intravenous urography, radionuclide scanning, cystography, and, in those who died in the early neonatal period, necropsy. Neonates who were referred with a known obstructed kidney had nephrostomy or pyeloplasty. End point - Assessment of the value of antenatal diagnosis of renal abnormalities on ultrasonography for babies who had no clinical evidence of disease postnatally. Main results - Eighteen fetuses did not survive birth; the antenatal diagnosis was accurate in a1118. Of the 44 babies born alive, five had normal urinary tracts, in two of whom antenatal ultrasonography had probably indicated a false positive diagnosis. Fourteen babies died during the early neonatal period. Twenty five babies with renal abnormalities were followed up; the antenatal diagnosis was inaccurate for IO of them, the commonest misdiagnosis
Citations from the Literature being hydronephorsis from multicystic kidney and vice versa, and there was one false positive diagnosis. The initial clinical findings in 14 babies would have led to the early detection of a urological abnormality. In the 30 babies with no clinical evidence of disease the antenatal diagnosis was of definite value in eight, probable value in 15, and marginal value in seven. Overall, an accurate antenatal diagnosis was made in 46 of the 62 cases (74070);in 12 cases renal disease was detected but its specific nature was not determined; and in four cases the diagnosis was misleading. Conclusions - The overall value of antenatal diagnosis is that it indicates early termination of fetuses with renal disease, prepares parents and medical staff for the likelihood of serious neonatal problems, and shows abnormalities of the urinary tract that may not be detected postnatally. Antenatal ultrasonography to detect fetal renal abnormalities: A prospective screening programme
Livera LN; Brookfield DSK; Egginton JA; Hawnaur JM North Staffordshire, Maternity Hospital, Stoke on Trent ST4 6SD; United Kingdom BR MED J/298/6685 (1421-1423)/1989/ Objective - To evaluate screening for abnormalities of the fetal renal tract by ultrasonography and to determine the incidence of such abnormalities in a population. Design - A 12 month prospective population study. Follow up of infants to between 9 and 18 months. Setting - A district general hospital. Participants - 6292 Pregnant women reaching 28 weeks’ gestation within the study period. Interventions - Antenatal ultrasound scanning was offered to all of the women. Babies in whom an abnormality of the renal tract had been detected antenatally underwent ultrasound scanning at the end of the first week. If the abnormality was confirmed contrast radiography was performed. End point - Confirmation of suspected rneal abnormality by postnatal investigations. Detection of abnormality in children thought to be normal antenatally. Measurements and main results - Of the 92 babies who had abnormal antenatal scans, 42 had abnormalities confirmed postnatally. Four of them died and 21 had had or were awaiting an operation at 18 months’ follow up. Seven children had renal abnormalities that were missed antenatally. The incidence of abnormalities detected by screening antenatally was 0.65%, and the overall incidence at 18 months’ follow up was 0.76%. Conclusions - The incidence of structural renal abnormalities in babies is higher than reported previously. Antenatal ultrasonography is an effective way of detecting such abnormalities. Bilateral fetal uropathy: What is the outlook?
Arthur RJ; Irving HC; Thomas DFM; Watters JK Department of Diagnostic Radiology, General Infirmary, Leeds; United Kingdom BR MED J/298/6685 (1419-1420)/1989/ Objective - To assess the morbidity and mortality associated with a prenatal diagnosis of bilateral fetal uropathy. Design - Retrospective study. Setting - Departments of radiology, paediatric surgery, obstetrics, and pathology in two teaching hospitals that serve as referral centres for the
93
Yorkshire region. Patients - 126 Cases of fetal uropathy were referred either prenatally or postnatally from hospitals in Yorkshire between August 1982 and December 1987. The disease was bilateral in 54 cases and unilateral in 72 cases. In 14 cases bilateral fetal uropathy was associated with co-existent disease. Interventions - All cases were managed individually by an obstetrician after discussion with the radiologists and paediatric surgeons. Babies who survived were treated prophylactically with antibiotics after delivery and were operated on if appropriate. End point - Assessment of prognosis for long term renal function for each baby referred between August 1982 and December 1987: follow up ranged from six months to five years. Measurements and main results - Of the 54 fetuses with bilateral fetal uropathy, 13 were terminated as the prenatal findings of ultrasonography were considered to be incompatible with long term survival. Ten of the liveborn babies died, five of renal or pulmonary insufficiency, or both, and five of associated congenital anomalies. Thirty one infants survived to follow up; four of these had serious coexistent disease and two had impaired renal function. Thus the overall mortality was 43% and the morbidity rate 19%. The renal anomaly was associated with other serious disease in 14 cases (26%) compared with two (370) of the 72 cases of unilateral fetal uropathy. All but two of the 27 infants with isolated bilateral urinary tract disease had excellent prospects for survival. Conclusion - Although bilateral fetal uropathy is associated with a high morbidity rate and mortality, careful prenatal assessment can help to identify fetuses with a poor prognosis. The outlook for a fetus with isolated renal disease if treated promptly after delivery is excellent and compares favourably with that reported after prenatal surgical intervention.
Episiotomy and its role in the incidence of perineal lacerations in a maternity center and a tertiary hospital obstetric service
Wilcox LS; Strobino DM; Baruffi G; Dellinger WS Jr Department of Maternal and Child Health, The Johns Hopkins University School of Hygiene and Public Health, Baltimore, MD; USA American Journal of Obstetrics and Gynecology/l60/5 I (1047 -1052)/1989/ This study examines the use of episiotomy and the frequency of perineal lacerations in a primary care maternity center staffed by certified nurse-midwives (Booth Maternity Center) and a tertiary care teaching hospital where deliveries were performed by physicians (Thomas Jefferson University Hospital). The study sample (1262 women) was a stratified random selection of singleton live births in 1977 and 1978 at Booth Maternity Center and Thomas Jefferson University Hospital, with the demographic characteristics of women at Booth Maternity Center used as the sampling frame. Data were abstracted from medical records. Clinical and demographic factors that might be associated with the likelihood of having an episiotomy or experiencing a perineal laceration were examined using logistic regression. After controlling for other significant factors, women at Thomas Jefferson University Hospital were twice as likely to have an episiotomy as women Int J Gynecol Obstet 31
Citations from the Literature
that a short-term infusion of magnesium sulfate leads to a sustained decline in palsma renin activity in preeclamptic wonmen, but exerts no sustained effect on angiotensin-converting enzyme in women with either preeclampsia or preterm labor. Synchronous intrauterine with clomiphene citrate
and ectopic
pregnancy
associated
Raccuia JS; Neckles S; Butler D; Kahn M; Ibrahim IM Department of Surgery, Englewood Hospital, Englewood, NJ 07062; USA Surgery Gynecology & Obstetrics/l68/5 (417-420)/1989/ Although synchronous intrauterine and ectopic pregnancies associated with the use of clomiphene citrate for infertility are rare, the actual incidence might, in fact, be considerably higher than previously thought. The cornerstone for ruling out an extrauterine gestation is the presence of sonographic evidence of an intrauterine pregnancy, as the possibility of concomitant intrauterine and extrauterine gestation is perceived to be statistically rare. This has resulted in an unacceptably high incidence of negative ultrasound interpretations. During a recent 12 month period, four women treated with clomiphene citrate for infertility were diagnosed as having concomitant intrauterine and ectopic pregnancies. Three had pelvic sonograms that were erroneous for the extrauterine component. However, successful evacuation of the products of ectopic gestation was performed in each, despite an immediate preoperative falsenegative ultrasound report. Three of the women delivered healthy normal infants at full term, and the fourth woman spontaneously aborted the products of the concomitant intrauterine gestation. All four did well postoperatively, and no gross complications were encountered. Reassessment of ultrasound diagnostic criteria and the use of more sensitive mehtods, such as endovaginal ultrasound in high risk patients, are indicated for any symptomatic patient using clomiphene citrate for infertility. Awareness of the prevalence of this entity and the limitations of ultrasound will lead to prompt intervention and improved survival rates. Inhibin: A new circulating marker of hydatidiform
mole?
Yohkaichiya T; Fukaya T; Hoshiai H; Yajima A; De Kretser DM Department of Anatomy, Monash University, Clayton, SA 3168; Australia BR MED J/298/6689 (1684--1686)/1989/ Objective - To define the concentrations of inhibin in serum and tissue of patients with hydatidiform mole and assess their value as a clinical marker of the condition. Design Prospective study of new patients with hydatidiform mole, comparison of paired observation, and case-control analysis. Setting-A university hospital, two large public hospitals, and a private women’s clinic in Japan. Patients - Seven consecutive referred patients seen over four months with newly diagnosed complete hydatidiform mole, including one in whom the mole was accompanied by viable twin fetuses (case excluded from statistical analysis because of unique clinical features). All patients followed up for six months after evacuation of molar tissue. End point - Correlation of serum inhibin conInt J Gynecol Obstet 31
centrations with trophoblastic disease. Measurements and main results - Serum concentrations of inhibin, human chorionic gonadotrophin, and follicle stimulating hormone were compared before and seven to 10 days after evacuation of the mole. Before evacuation the serum inhibin concentrations (median 8.3 U/ml; 95% confidence interval 2.4 to 34.5) were significantly greater than in 21 normal women at the same stage of pregnancy (2.8 U/ml; 2.1 to 3.6), and inhibin in molar tissue was also present in high concentrations (578 U/ml cytosol; 158 to 1162). Seven to 10 days after evacuation inhibin concentrations in serum samples from the same patients declined significantly to values (0.4 U.mI; 0.1 to 1.4) similar to those seen in the follicular phase of normal menstrual cycles. None of the four patients whose serum inhibin concentrations were 0.4 U/m1 or less after evacuation developed persistent trophohlastic disease. Though serum human chorionic gonadotrophin concentrations declined after evacuation (6.6 x lo) III/l; 0.8 x lo3 to 32.6 x lo), they remained far higher than in non-pregnant women. Serum follicle stimulating hormone concentrations remained suppressed. Conclusions - In this small study serum inhibin concentrations higher than those found in the early follicular phase one to two weeks after evacuation of a hydatidiform mole seemed to be specific for persistent trophoblastic disease. Further data are needed to confirm these promising results.
Value of antenatal tract
diagnosis
of abnormalities
of the urinary
Greig JD; Raine PAM; Young DC; Azmy AF; MacKenzie JR; Danskin F; Whittle MJ; McNay MB Department of Paediatric Surgery, Royal Hospital for Sick Children, Glasgow, G3 8SJ; United Kingdom BR MED J/298/6685 (1417-1419)/1989) Objective - To assess the value of antenatal diagnosis of abnormalities of the urinary tract on ultrasonography. Design - Retrospective study. Setting - Two obstetric units in GIasgow. Subjects - 62 Fetuses in which renal abnormalities were diagnosed on antenatal ultrasonography. Interventions - Six fetuses had their bladders aspirated to determine renal function. Fifteen pregnancies were terminated on the basis of the findings on antenatal ultrasonography, and if possible necropsy was performed on the fetuses. In babies who were born alive the final diagnosis was made by postnatal ultrasonography, intravenous urography, radionuclide scanning, cystography, and, in those who died in the early neonatal period, necropsy. Neonates who were referred with a known obstructed kidney had nephrostomy or pyeloplasty. End point - Assessment of the value of antenatal diagnosis of renal abnormalities on ultrasonography for babies who had no clinical evidence of disease postnatally. Main results - Eighteen fetuses did not survive birth; the antenatal diagnosis was accurate in a1118. Of the 44 babies born alive, five had normal urinary tracts, in two of whom antenatal ultrasonography had probably indicated a false positive diagnosis. Fourteen babies died during the early neonatal period. Twenty five babies with renal abnormalities were followed up; the antenatal diagnosis was inaccurate for IO of them, the commonest misdiagnosis
Citations from the Literature being hydronephorsis from multicystic kidney and vice versa, and there was one false positive diagnosis. The initial clinical findings in 14 babies would have led to the early detection of a urological abnormality. In the 30 babies with no clinical evidence of disease the antenatal diagnosis was of definite value in eight, probable value in 15, and marginal value in seven. Overall, an accurate antenatal diagnosis was made in 46 of the 62 cases (74070);in 12 cases renal disease was detected but its specific nature was not determined; and in four cases the diagnosis was misleading. Conclusions - The overall value of antenatal diagnosis is that it indicates early termination of fetuses with renal disease, prepares parents and medical staff for the likelihood of serious neonatal problems, and shows abnormalities of the urinary tract that may not be detected postnatally. Antenatal ultrasonography to detect fetal renal abnormalities: A prospective screening programme
Livera LN; Brookfield DSK; Egginton JA; Hawnaur JM North Staffordshire, Maternity Hospital, Stoke on Trent ST4 6SD; United Kingdom BR MED J/298/6685 (1421-1423)/1989/ Objective - To evaluate screening for abnormalities of the fetal renal tract by ultrasonography and to determine the incidence of such abnormalities in a population. Design - A 12 month prospective population study. Follow up of infants to between 9 and 18 months. Setting - A district general hospital. Participants - 6292 Pregnant women reaching 28 weeks’ gestation within the study period. Interventions - Antenatal ultrasound scanning was offered to all of the women. Babies in whom an abnormality of the renal tract had been detected antenatally underwent ultrasound scanning at the end of the first week. If the abnormality was confirmed contrast radiography was performed. End point - Confirmation of suspected rneal abnormality by postnatal investigations. Detection of abnormality in children thought to be normal antenatally. Measurements and main results - Of the 92 babies who had abnormal antenatal scans, 42 had abnormalities confirmed postnatally. Four of them died and 21 had had or were awaiting an operation at 18 months’ follow up. Seven children had renal abnormalities that were missed antenatally. The incidence of abnormalities detected by screening antenatally was 0.65%, and the overall incidence at 18 months’ follow up was 0.76%. Conclusions - The incidence of structural renal abnormalities in babies is higher than reported previously. Antenatal ultrasonography is an effective way of detecting such abnormalities. Bilateral fetal uropathy: What is the outlook?
Arthur RJ; Irving HC; Thomas DFM; Watters JK Department of Diagnostic Radiology, General Infirmary, Leeds; United Kingdom BR MED J/298/6685 (1419-1420)/1989/ Objective - To assess the morbidity and mortality associated with a prenatal diagnosis of bilateral fetal uropathy. Design - Retrospective study. Setting - Departments of radiology, paediatric surgery, obstetrics, and pathology in two teaching hospitals that serve as referral centres for the
93
Yorkshire region. Patients - 126 Cases of fetal uropathy were referred either prenatally or postnatally from hospitals in Yorkshire between August 1982 and December 1987. The disease was bilateral in 54 cases and unilateral in 72 cases. In 14 cases bilateral fetal uropathy was associated with co-existent disease. Interventions - All cases were managed individually by an obstetrician after discussion with the radiologists and paediatric surgeons. Babies who survived were treated prophylactically with antibiotics after delivery and were operated on if appropriate. End point - Assessment of prognosis for long term renal function for each baby referred between August 1982 and December 1987: follow up ranged from six months to five years. Measurements and main results - Of the 54 fetuses with bilateral fetal uropathy, 13 were terminated as the prenatal findings of ultrasonography were considered to be incompatible with long term survival. Ten of the liveborn babies died, five of renal or pulmonary insufficiency, or both, and five of associated congenital anomalies. Thirty one infants survived to follow up; four of these had serious coexistent disease and two had impaired renal function. Thus the overall mortality was 43% and the morbidity rate 19%. The renal anomaly was associated with other serious disease in 14 cases (26%) compared with two (370) of the 72 cases of unilateral fetal uropathy. All but two of the 27 infants with isolated bilateral urinary tract disease had excellent prospects for survival. Conclusion - Although bilateral fetal uropathy is associated with a high morbidity rate and mortality, careful prenatal assessment can help to identify fetuses with a poor prognosis. The outlook for a fetus with isolated renal disease if treated promptly after delivery is excellent and compares favourably with that reported after prenatal surgical intervention.
Episiotomy and its role in the incidence of perineal lacerations in a maternity center and a tertiary hospital obstetric service
Wilcox LS; Strobino DM; Baruffi G; Dellinger WS Jr Department of Maternal and Child Health, The Johns Hopkins University School of Hygiene and Public Health, Baltimore, MD; USA American Journal of Obstetrics and Gynecology/l60/5 I (1047 -1052)/1989/ This study examines the use of episiotomy and the frequency of perineal lacerations in a primary care maternity center staffed by certified nurse-midwives (Booth Maternity Center) and a tertiary care teaching hospital where deliveries were performed by physicians (Thomas Jefferson University Hospital). The study sample (1262 women) was a stratified random selection of singleton live births in 1977 and 1978 at Booth Maternity Center and Thomas Jefferson University Hospital, with the demographic characteristics of women at Booth Maternity Center used as the sampling frame. Data were abstracted from medical records. Clinical and demographic factors that might be associated with the likelihood of having an episiotomy or experiencing a perineal laceration were examined using logistic regression. After controlling for other significant factors, women at Thomas Jefferson University Hospital were twice as likely to have an episiotomy as women Int J Gynecol Obstet 31