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Fetal intracranial hemorrhage: Clinical significance of in utero ultrasonographic diagnosis
356
Citations from the literature / Int. J. Gyneeol. Obstet. 46 (1994) 351-358
born at 22 weeks. Whether the occasional child who is born at 23 or 24 weeks’ gestation and does well justifies the considerable mortality and morbidity of the majority is a question that should be discussed by parents, health care providers, and society. Neonatal complications after the administration of indomethacin for preterm labor Norton ME.; Merrill J.; Cooper B.A.B.; Kuller J.A.; Clyman R.I. USA NEW ENGL J MED 1993/329/22 (1602-1607) Background. The use of indomethacin as a tocolytic agent in pregnant women appears to be accompanied by a low incidence of neonatal complications. However, the neonatal effects of indomethacin have been studied primarily in infants born after 32 weeks’ gestation. This study was designed to examine the incidence of neonatal complications in very premature infants. Methods. We identified 57 infants delivered at or before 30 weeks’ gestation whose mothers had been treated with indomethacin for preterm labor and matched them with 57 infants whose mothers had not received indomethacin. The infants in the two groups were matched for sex, gestational age at delivery (mean [*SD.], 27.6 f 2.0 weeks), exposure to betamethasone for 24 h or more before delivery, and rupture of membranes 24 h or more before delivery. Results. There were no significant differences between the two groups in birth weight, Apgar scores, cord-blood gas values, frequency of multiple gestation, or incidence of respiratory distress syndrome. The proportion of infants who required exogenous surfactant was similar, as were ventilator settings at 24 hours, the incidence of chronic lung disease, and the incidence of sepsis. The infants exposed to indomethacin had a lower urine output and higher serum creatinine concentrations during the first three days after delivery. More indomethacin-exposed infants had necrotizing enterocolitis (29% vs. 8%, P = 0.005) intracranial hemorrhage grade II to IV (28% vs. 9%, P = 0.02), and patent ductus arteriosus (62% vs. 44%, P = 0.05). More indomethacinexposed infants with a patent ductus arteriosus required surgical ligation because of either a lack of initial response or a reopening of the duct after postnatal indomethacin therapy (50% vs. 20% of the unexposed infants, P = 0.05). Conclusions. Antenatal indomethacin therapy for preterm labor appears to increase the risk of serious neonatal complications in infants born at or before 30 weeks’ gestation. Doppler ultrasound screening as part of routine antenatal scanning: Prediction of pre-eclampsia and intrauterine growth retardation Bower S.; Schuchter K.; Campbell S. GBR BR J OBSTET GYNAECOL 1993/100/l I (989-994) Objective: To assess the value of incorporating continuous wave Doppler ultrasound of the uterine arteries into the routine scan as a screening test in an unselected population. Design: A cross sectional study by multiple operators using continuous wave Doppler ultrasound to obtain flow velocity waveforms
(FVW) from both uterine arteries of all women attending for routine anomaly scan at I8 to 22 weeks over a period of I2 months. An abnormal FVW in either uterine artery was used to predict intrauterine death, antepartum hemorrhage and three different degrees of severity of preeclampsia and growth retardation, singly and in combination. Setting: King’s College Hospital, London. Subjects: Two thousand, four hundred and thirty women attending for routine anomaly ultrasound scan. Results: A total of 2430 women were scanned with a 90% follow-up rate. The results demonstrate higher sensitivities than previous studies, but with a high proportion of false positive tests. By including an early diastolic notch in the definition of an abnormal FVW the prediction of pre-eclampsia is markedly improved; the relative risk to a woman with an abnormal waveform of developing moderate or severe pre-eclampsia is increased 24-fold. Although the positive predictive value for babies less than the 5th centile for gestation is only 15%. those at risk of neonatal complications may be identified. Conclusion: This simple test can be performed at a routine visit and a group of women can be identified for further assessment and possible therapeutic intervention. Electroencephalogram and computerized cerebral tomography finding.9in ectampsia Moodley J.; Bobat S.M.; Hoffman M.; Bill P.L.A. ZAF BR J OBSTET GYNAECOL 1993/100/1I (984-988) Objective: To define more clearly the neuropathophysiology of eclampsia. Design. A prospective study relating to computerized cerebral tomography (CAT) scan and electroencephalogram (EEG) findings in eclampsia. Setting: A large referral center in a developing society. Subjects: Thirty-two women with eclampsia. Main outcome measures: Abnormalities in EEG and CAT scan findings. Results: Approximately 45% of the women studied had CAT scan abnormalities, while 90% had EEG abnormalities. A burst suppression pattern on EEG examination was found in four women suggesting a temporary dissolution of cerebral function to the midbrain level as the cause of seizures. Conclusions: EEGs are probably more sensitive than CAT scans in detecting the extent of the pathology in the brain in women with eclampsia. Fetal intracranial hemorrhage: Clinical significance of in utero ultrasonographic diagnosis Achiron R.; Pinchas O.H.; Reichman B.; Heyman Z.; Schimmel M.; Eidelman A.; Mashiach S. ISR BR J OBSTET GYNAECOL 1993/100/l I (995-999) Objective: To review in utero detection of fetal intracranial hemorrhage. Design: Retrospective survey of pregnant women presenting to the ultrasonographic unit in whom the diagnosis of fetal intracranial hemorrhage was reached. Setting: The Chaim Sheba Medical Center in Ramat Gan, and Shaare Zedek Medical Center in Jerusalem; two large district general hospitals, each with 6000 maternity patients per year. Subjects: Five fetuses with gestational ages ranging from 26 to 36 weeks. Main outcome measures: Maternal complications, fetal monitoring,
Citations .from the literature / Int. J. Gynecol. Obstet. 46 (1994) 351-358
prenatal Doppler ultrasound studies, postnatal imaging studies, neonatal morbidity and mortality. Results: Transabdominal sonography showed hyperechoic lesions in the brain parenchyma, and the lateral ventricle in three of five fetuses. In the remaining two fetuses, transvaginal sonography enhanced the visualization of ventriculomegaly with intraventricular hemorrhage in one and periventricular leukomalacia was identified in the second. Three fetuses were appropriate for gestational age, and two were severely growth retarded. In one woman severe pre-eclamptic toxemia may explain intracranial hemorrhage. Abnormal nonstress test and abnormal flow velocity waveforms in the umbilical and cerebral arteries were present in the two growth retarded fetuses, and in one who was appropriate for gestational age. The two growth retarded fetuses died shortly after birth. Of the three surviving infants, two had normal long term development, and one developed hydrocephalus with subsequent severe neurodevelopmental retardation, dying at the age of seven months. Conclusions: This small series shows that intracranial hemorrhage has a broad spectrum of manifestations with diverse prognosis. Following an antenatal diagnosis of intracranial hemorrhage, the obstetrician must give special consideration to electronic fetal heart monitoring and Doppler velocity waveforms. The prenatal diagnosis of intracranial hemorrhage has medico-legal implications suggesting that neurological outcome may not necessarily be due solely to intrapartum events and management. Uterhe artery JhqpIer velocity waveforms in twin pregnancies Rizzo G.; Arduini D.; Romanini C. ITA
OBSTET GYNECOL 1993/82/6 (978-983) Objective: To compare uterine artery resistance index values in twin and singleton pregnancies, to examine eventual modifications of these values in twin pregnancies complicated by gestational hypertension and preeclampsia, and to determine whether resistance index values in twin pregnancies could predict the development of gestational hypertension and preeclampsia. Methods: In a cross-sectional study, reference limits for gestation were constructed for the uterine artery resistance index (higher, lower, and mean values) in 96 uncomplicated twin pregnancies and compared to the reference limits constructed from 315 normal singleton pregnancies. Uterine artery resistance indexes obtained in 53 twin pregnancies complicated by either gestational hypertension or preeclampsia were compared with the newly established nomograms. The clinical efficacy of the uterine artery resistance index to predict hypertensive complications was evaluated prospectively in 64 twin pregnancies studied at 20-24 weeks’ gestation. Results: In both singleton and twin pregnancies, uterine artery resistance indexes decreased linearly with advancing gestation. However, twin pregnancies showed significantly different slopes and constant values, resulting in lower resistance indexes at all gestational ages examined. No significant differences were found when comparing resistance indexes in all patients with gestational hypertension or preeclampsia to the reference limits. Statistically significant differences were ob-
357
tained for the higher (P s 0.05) and mean (P 5 0.01) resistance indexes when the comparison was restricted to preeclamptic patients. In the twin pregnancies studied at 20-24 weeks’gestation, the diagnostic efficacy of the uterine artery resistance index for predicting the development of gestational hypertension and/or preeclampsia was disappointing low (k < 0.10). Conclusions: Resistance index values in the uterine artery are lower in twin pregnancies than in singleton pregnancies. Gestational hypertension and preeclampsia may occur in twin pregnancies despite normal uterine artery velocity waveforms, suggesting a limited role of this measurement in the management and prediction of hypertensive complications in twin pregnancies. SereenIng for HIV-l antibodies in pregnamzy:Resdts from the Swedish donal program Lindgren S.; Bohlin A.-B.; Forsgren M.; Arneborn M.; Ottenblad C.; Lidman K.; Anzen B.; Von Sydow M.; Bottiger M. SWE
BR MED J 1993/307/6917(1447-1451) Objective - To determine the effectiveness of a national screening program for HIV infection in pregnant women. Design - Observational study. Subjects - All pregnant women presenting to antenatal or abortion clinics. Setting - Sweden, September 1987 to December 1991. Main outcome measures Number and characteristics of infected women. Results - By the end of the study period 5 10 000 tests had been performed and 54 women with HIV infection identified (I .06/10 000). Of the 33 women identified in Stockholm, 14 women (4.4/10 000) had attended abortion clinics and 19 antenatal clinics (1.8/10 000; P s: 0.05). Three women had been intravenous drug users, one was infected through a blood transfusion, and 50 were probably infected sexually. Of the 20 women who attended antenatal clinics early enough to allow an abortion, 12 continued with their pregnancies. Conclusions - Testing of all women, not just those perceived to be at risk, probably contributed to the high uptake of HIV testing. With high uptake such screening provides valuable data on spread of HIV in the heterosexual population and presents opportunity for preventing transmission of HIV to children and partners. Fetal immmmdeficiency:A consequenceof placental insufficiency Thilaganathan B.; Plachouras N.; Makrydimas G.; Nicolaides K.H. CBR
BR J OBSTET GYNAECOL 1993/100/l 1 (1000-1004) Objective: To study the effect of placental insufficiency on fetal lymphocyte subpopulations. Study design: Cross sectional study of 19 growth retarded fetuses undergoing cordocentesis at 24 to 37 weeks gestation. Flow cytometry was used to enumerate fetal blood lymphocyte subpopulations. Results: The mean T(CD3+), B(CD19+), T-helper (CD4+), T-suppressor/cytotoxic (CD8+) cell counts and the CD4 to CD8 ratio in the growth retarded fetuses were significantly lower than the respective normal mean for gestation (CD3+: z = 3.66, P < 0.001; CD19+: z = 2.18, P < 0.05; CD4+: z = 3.76, P < 0.001; CD8+: z = 2.26, P < 0.05; and CD4/CD8: z = 2.27, P < 0.05).
Citations from the literature / Int. J. Gyneeol. Obstet. 46 (1994) 351-358
born at 22 weeks. Whether the occasional child who is born at 23 or 24 weeks’ gestation and does well justifies the considerable mortality and morbidity of the majority is a question that should be discussed by parents, health care providers, and society. Neonatal complications after the administration of indomethacin for preterm labor Norton ME.; Merrill J.; Cooper B.A.B.; Kuller J.A.; Clyman R.I. USA NEW ENGL J MED 1993/329/22 (1602-1607) Background. The use of indomethacin as a tocolytic agent in pregnant women appears to be accompanied by a low incidence of neonatal complications. However, the neonatal effects of indomethacin have been studied primarily in infants born after 32 weeks’ gestation. This study was designed to examine the incidence of neonatal complications in very premature infants. Methods. We identified 57 infants delivered at or before 30 weeks’ gestation whose mothers had been treated with indomethacin for preterm labor and matched them with 57 infants whose mothers had not received indomethacin. The infants in the two groups were matched for sex, gestational age at delivery (mean [*SD.], 27.6 f 2.0 weeks), exposure to betamethasone for 24 h or more before delivery, and rupture of membranes 24 h or more before delivery. Results. There were no significant differences between the two groups in birth weight, Apgar scores, cord-blood gas values, frequency of multiple gestation, or incidence of respiratory distress syndrome. The proportion of infants who required exogenous surfactant was similar, as were ventilator settings at 24 hours, the incidence of chronic lung disease, and the incidence of sepsis. The infants exposed to indomethacin had a lower urine output and higher serum creatinine concentrations during the first three days after delivery. More indomethacin-exposed infants had necrotizing enterocolitis (29% vs. 8%, P = 0.005) intracranial hemorrhage grade II to IV (28% vs. 9%, P = 0.02), and patent ductus arteriosus (62% vs. 44%, P = 0.05). More indomethacinexposed infants with a patent ductus arteriosus required surgical ligation because of either a lack of initial response or a reopening of the duct after postnatal indomethacin therapy (50% vs. 20% of the unexposed infants, P = 0.05). Conclusions. Antenatal indomethacin therapy for preterm labor appears to increase the risk of serious neonatal complications in infants born at or before 30 weeks’ gestation. Doppler ultrasound screening as part of routine antenatal scanning: Prediction of pre-eclampsia and intrauterine growth retardation Bower S.; Schuchter K.; Campbell S. GBR BR J OBSTET GYNAECOL 1993/100/l I (989-994) Objective: To assess the value of incorporating continuous wave Doppler ultrasound of the uterine arteries into the routine scan as a screening test in an unselected population. Design: A cross sectional study by multiple operators using continuous wave Doppler ultrasound to obtain flow velocity waveforms
(FVW) from both uterine arteries of all women attending for routine anomaly scan at I8 to 22 weeks over a period of I2 months. An abnormal FVW in either uterine artery was used to predict intrauterine death, antepartum hemorrhage and three different degrees of severity of preeclampsia and growth retardation, singly and in combination. Setting: King’s College Hospital, London. Subjects: Two thousand, four hundred and thirty women attending for routine anomaly ultrasound scan. Results: A total of 2430 women were scanned with a 90% follow-up rate. The results demonstrate higher sensitivities than previous studies, but with a high proportion of false positive tests. By including an early diastolic notch in the definition of an abnormal FVW the prediction of pre-eclampsia is markedly improved; the relative risk to a woman with an abnormal waveform of developing moderate or severe pre-eclampsia is increased 24-fold. Although the positive predictive value for babies less than the 5th centile for gestation is only 15%. those at risk of neonatal complications may be identified. Conclusion: This simple test can be performed at a routine visit and a group of women can be identified for further assessment and possible therapeutic intervention. Electroencephalogram and computerized cerebral tomography finding.9in ectampsia Moodley J.; Bobat S.M.; Hoffman M.; Bill P.L.A. ZAF BR J OBSTET GYNAECOL 1993/100/1I (984-988) Objective: To define more clearly the neuropathophysiology of eclampsia. Design. A prospective study relating to computerized cerebral tomography (CAT) scan and electroencephalogram (EEG) findings in eclampsia. Setting: A large referral center in a developing society. Subjects: Thirty-two women with eclampsia. Main outcome measures: Abnormalities in EEG and CAT scan findings. Results: Approximately 45% of the women studied had CAT scan abnormalities, while 90% had EEG abnormalities. A burst suppression pattern on EEG examination was found in four women suggesting a temporary dissolution of cerebral function to the midbrain level as the cause of seizures. Conclusions: EEGs are probably more sensitive than CAT scans in detecting the extent of the pathology in the brain in women with eclampsia. Fetal intracranial hemorrhage: Clinical significance of in utero ultrasonographic diagnosis Achiron R.; Pinchas O.H.; Reichman B.; Heyman Z.; Schimmel M.; Eidelman A.; Mashiach S. ISR BR J OBSTET GYNAECOL 1993/100/l I (995-999) Objective: To review in utero detection of fetal intracranial hemorrhage. Design: Retrospective survey of pregnant women presenting to the ultrasonographic unit in whom the diagnosis of fetal intracranial hemorrhage was reached. Setting: The Chaim Sheba Medical Center in Ramat Gan, and Shaare Zedek Medical Center in Jerusalem; two large district general hospitals, each with 6000 maternity patients per year. Subjects: Five fetuses with gestational ages ranging from 26 to 36 weeks. Main outcome measures: Maternal complications, fetal monitoring,
Citations .from the literature / Int. J. Gynecol. Obstet. 46 (1994) 351-358
prenatal Doppler ultrasound studies, postnatal imaging studies, neonatal morbidity and mortality. Results: Transabdominal sonography showed hyperechoic lesions in the brain parenchyma, and the lateral ventricle in three of five fetuses. In the remaining two fetuses, transvaginal sonography enhanced the visualization of ventriculomegaly with intraventricular hemorrhage in one and periventricular leukomalacia was identified in the second. Three fetuses were appropriate for gestational age, and two were severely growth retarded. In one woman severe pre-eclamptic toxemia may explain intracranial hemorrhage. Abnormal nonstress test and abnormal flow velocity waveforms in the umbilical and cerebral arteries were present in the two growth retarded fetuses, and in one who was appropriate for gestational age. The two growth retarded fetuses died shortly after birth. Of the three surviving infants, two had normal long term development, and one developed hydrocephalus with subsequent severe neurodevelopmental retardation, dying at the age of seven months. Conclusions: This small series shows that intracranial hemorrhage has a broad spectrum of manifestations with diverse prognosis. Following an antenatal diagnosis of intracranial hemorrhage, the obstetrician must give special consideration to electronic fetal heart monitoring and Doppler velocity waveforms. The prenatal diagnosis of intracranial hemorrhage has medico-legal implications suggesting that neurological outcome may not necessarily be due solely to intrapartum events and management. Uterhe artery JhqpIer velocity waveforms in twin pregnancies Rizzo G.; Arduini D.; Romanini C. ITA
OBSTET GYNECOL 1993/82/6 (978-983) Objective: To compare uterine artery resistance index values in twin and singleton pregnancies, to examine eventual modifications of these values in twin pregnancies complicated by gestational hypertension and preeclampsia, and to determine whether resistance index values in twin pregnancies could predict the development of gestational hypertension and preeclampsia. Methods: In a cross-sectional study, reference limits for gestation were constructed for the uterine artery resistance index (higher, lower, and mean values) in 96 uncomplicated twin pregnancies and compared to the reference limits constructed from 315 normal singleton pregnancies. Uterine artery resistance indexes obtained in 53 twin pregnancies complicated by either gestational hypertension or preeclampsia were compared with the newly established nomograms. The clinical efficacy of the uterine artery resistance index to predict hypertensive complications was evaluated prospectively in 64 twin pregnancies studied at 20-24 weeks’ gestation. Results: In both singleton and twin pregnancies, uterine artery resistance indexes decreased linearly with advancing gestation. However, twin pregnancies showed significantly different slopes and constant values, resulting in lower resistance indexes at all gestational ages examined. No significant differences were found when comparing resistance indexes in all patients with gestational hypertension or preeclampsia to the reference limits. Statistically significant differences were ob-
357
tained for the higher (P s 0.05) and mean (P 5 0.01) resistance indexes when the comparison was restricted to preeclamptic patients. In the twin pregnancies studied at 20-24 weeks’gestation, the diagnostic efficacy of the uterine artery resistance index for predicting the development of gestational hypertension and/or preeclampsia was disappointing low (k < 0.10). Conclusions: Resistance index values in the uterine artery are lower in twin pregnancies than in singleton pregnancies. Gestational hypertension and preeclampsia may occur in twin pregnancies despite normal uterine artery velocity waveforms, suggesting a limited role of this measurement in the management and prediction of hypertensive complications in twin pregnancies. SereenIng for HIV-l antibodies in pregnamzy:Resdts from the Swedish donal program Lindgren S.; Bohlin A.-B.; Forsgren M.; Arneborn M.; Ottenblad C.; Lidman K.; Anzen B.; Von Sydow M.; Bottiger M. SWE
BR MED J 1993/307/6917(1447-1451) Objective - To determine the effectiveness of a national screening program for HIV infection in pregnant women. Design - Observational study. Subjects - All pregnant women presenting to antenatal or abortion clinics. Setting - Sweden, September 1987 to December 1991. Main outcome measures Number and characteristics of infected women. Results - By the end of the study period 5 10 000 tests had been performed and 54 women with HIV infection identified (I .06/10 000). Of the 33 women identified in Stockholm, 14 women (4.4/10 000) had attended abortion clinics and 19 antenatal clinics (1.8/10 000; P s: 0.05). Three women had been intravenous drug users, one was infected through a blood transfusion, and 50 were probably infected sexually. Of the 20 women who attended antenatal clinics early enough to allow an abortion, 12 continued with their pregnancies. Conclusions - Testing of all women, not just those perceived to be at risk, probably contributed to the high uptake of HIV testing. With high uptake such screening provides valuable data on spread of HIV in the heterosexual population and presents opportunity for preventing transmission of HIV to children and partners. Fetal immmmdeficiency:A consequenceof placental insufficiency Thilaganathan B.; Plachouras N.; Makrydimas G.; Nicolaides K.H. CBR
BR J OBSTET GYNAECOL 1993/100/l 1 (1000-1004) Objective: To study the effect of placental insufficiency on fetal lymphocyte subpopulations. Study design: Cross sectional study of 19 growth retarded fetuses undergoing cordocentesis at 24 to 37 weeks gestation. Flow cytometry was used to enumerate fetal blood lymphocyte subpopulations. Results: The mean T(CD3+), B(CD19+), T-helper (CD4+), T-suppressor/cytotoxic (CD8+) cell counts and the CD4 to CD8 ratio in the growth retarded fetuses were significantly lower than the respective normal mean for gestation (CD3+: z = 3.66, P < 0.001; CD19+: z = 2.18, P < 0.05; CD4+: z = 3.76, P < 0.001; CD8+: z = 2.26, P < 0.05; and CD4/CD8: z = 2.27, P < 0.05).