- Email: [email protected]
Fetal movements in multiple pregnancy
Fetal sex-related differences in a-fetoprotein
Volume 146 Number 7
conclude that fetal sex is an additional source of variability in measurable maternal serum a-fetoprotein during the second trimester. The underlying cause or causes of this phenomenon remain unknown.
Male Fetuses
60
We acknowledge the support and efforts of the participating physicians in Forsyth and Guilford Counties, without whom this project would not have been possible.
40
20
REFERENCES I. Haddow,]. E., Macri,J. N., and Munson, M.: The amnion
c:
Q)
E
0
0
3: 0 Cii
.Q
E
2.
39.1
100
aoimm
200 3.
Female Fetuses
::J
z
4.
60
5.
6. 7.
36.6
80
160
240
320
400
ng I ml
Fig. 2. Actual distributions of maternal serum a-fetoprotein values between 15 and 19 weeks' gestation in women segregated according to the sex of the fetus. The mean value for each group is indicated by an arrow.
8. 9.
regulates movement of fetally derived alpha fetoprotein into maternal blood, J. Lab. Clin. Med. 94:344, 1979. Haddow, J. E., Kloza, E. M., Knight, G. J., and Smith, D. E.: Relation between maternal weight and serum alpha fetoprotein concentration during the second trimester, Clin. Chern. 27:133, 1981. Crandall, B. F., Schroth, P. 0., and Lebherz, T. B.: Racial differences in maternal serum aipha-fetoprotein ieveis (MSAFP), Am. J. Hum. Genet. 34:85A, 1982. Gardner, S., Burton, B. K., and Johnson, A. M.: Maternal serum alpha fetoprotein screening: A report of the Forsyth County Project, AM.]. OBSTET. GYNECOL. 140:250, 1981. United Kingdom Collaborative Study on alpha fetoprotein in relation to neural tube defects: Maternal serum alpha fetoprotein measurement in antenatal screening for anencephaly and spina bifida in early pregnancy, Lancet 1: 1323, 1977. Box, G. E. P., and Cox, D. R.: An analysis of transformations, J. R. Stat. Soc. %6:2ll, 1964. Iffy, L., .Lavenhar, M., Kaminetzky, H. A., Jonllbloet, P. H., Wmgate, M. B., and Jakobovlts, A.: The eftect of maternal age, parity, fetal sex and season upon early intrauterine development, Int. J. Gynaecol. Obstet. 16:210, 1978. Lardinois, R., Anagnostakis, D., Ortexz, M.A., and Delisle, M.: Human a 1-foetoglobulin during the last trimester of gestation, Clin. Chim. Acta 37:81, 1972. Milunsky, A., Alpert, E., Neff, R. K., and Frigoletro, F. D.: Prenatal diagnosis of neural tube defects. IV. Maternal serum alpha-fetoprotein screening, Obstet. Gynecol. 55: 60, 1980.
Fetal movements in multiple pregnancy A. Satnueloff, S. Evron, and E. Sadovsky Jerusalem, Israel Fetal activity in multiple pregnancies, as expressed by matemal daily fetal movement recordings, was compared with that in singleton pregnancies. It was found that the mean fetal activity in 33 cases of twins, six cases of triplets, one case of quadruplets, and one case of quintuplets was generally higher than that obtained during singleton pregnancies. In most cases, fetal movements of triplets, quadruplets, and quintuplets were even higher than the movement of twins. (AM. J. O!!!TET. GYNEOO-· 146:789, 1983.)
From the High Risk Pregnancy Unit, Department of Obstetrics and Gynecology, Hadassah University Hospital. Received for publicatWn August 24, 1982. Revi5ed December 21, 1982.
Accepted March 11, 1983. Reprint requests: Dr. A. Samueloff, Department of Obstetrics and Gynecolcgy, Hadassah University Hospital, Jerusalem. Israel.
789
790
Samueloff, Evron, and Sadovsky
August I, 1983
Am.
Fetal activity reveals the fetal condition in utero, and daily monitoring of fetal movements provides a good criterion by which to estimate fetal well-being. 1 - 4 Every pregnancy has its own fetal movement rate. 3• 4 The movements are sensed by the mother, whose ability to recognize them is influenced by her character and .education, and by gestational age. 3• 4 Wood and associates5 showed that maternal age, parity, ethnic origin, sex of the fetus, and amniotic fluid volume do not influence the mother's estimate of fetal movement. However, objective assessment of fetal movement showed that the frequency is influenced by parity. 6 It has been suggested that drugs, such as barbiturates and diazepam, reduce fetal movement. 7 An important factor that influences fetal movement is intrauterine hypoxia caused by diminished uteroplacental blood flow, as in preeclamptic toxemia. 3 We previously reported the weekly average of fetal movements in 127 pregnant women with a singleton pregnancy and normal outcome. 8 These patients recorded the number of fetal movements that they perceived during a 30-minute period three times a day. These values were used to estimate the fetal movements over 12 hours, and this 12-hour value was designated daily fetal movements recording. The mean daily fetal movement counts were found to increase from about 200 in the twentieth week of gestation to a maximum of 575 in the thirty-second week and gradually declined thereafter until delivery, with the mean fetal movement rate at the fortieth week being 282. It was suggested in the past that the rate of fetal movement is markedly elevated in cases of multiple pregnancy. The aim of this study was to evaluate the fetal activity in various types of multiple pregnancy.
Material and methods The subjects of this study were 41 pregnant women with multiple fetuses who were hospitalized in the High Risk Pregnancy Unit of Hadassah University Hospital, Jerusalem, Israel, for observation and rest in order to try to delay premature delivery as much as possible. In some cases, /3-mimetic drugs were given. It was previously found 9 • 10 that these drugs do not alter the daily fetal movement recording. An additional 27 cases of multiple pregnancy were discarded during this study because of complications or poor outcome. Table I shows the distribution of the subjects according to the number of fetuses and weeks of pregnancy when the fetal movements were assessed. There was a good outcome in all cases. No perinatal deaths or instances of fetal distress occurred during pregnancy or delivery, and the Apgar scores were at least 7. The women who participated in this study were
J. Obstet. Gynecol.
Table I. Clinical characteristics of the subjects examined (41 multiple pregnancies) No.
offetuses
I
No. of cases
I
of
33 6
Twins Triplets Quadruplets Quintuplets Total
;~ncy 26-40 26-36 27-33 29-34 26-40
l I
41
Table II. Statistical analysis data of differences between daily fetal movement rates in twin and singleton pregnancies at the same week of gestation Weeks of gestation
26 27 28 29 30 31 32 33 34 35 36 37 38 39 40
Twins
N
3 4 3 2 6 9 9 13 14 15 13 11
8 3 2
I Mean I SD 631 774 641 621 497 475 525 584 608 516 527 430 454 285 224
336 115 121 30 116 222 300 314 300 263 258 254 345 126 45
Singleton
N
9 9 11 16 15 16 15 16 26 29 25 17 17 12 10
I Mean I SD 394 493 493 451 443 444 520 477 442 402 450 363 368 280 282
172 176 269 188 195 162 260 232 199 160 238 201 140 254 226
p
<0.5 <0.05 <0.5 <0.5
NS NS NS <0.5 <0.02 <0.1 <0.5 <0.5 <0.5
NS NS
asked to assess the fetal movements they felt during a period of 30 minutes, after meals while lying in bed on their side. The measurements were made three times a day, in the morning, at noon, and in the evening. The number of fetal movements was calculated for 12 hours, thereby obtaining the daily fetal movement recording. The subjects were instructed to count a sequence of fetal movements as a single movement.
Results Fig. 1 shows the values of daily fetal movement rate (means ± SE) according to the week of gestation in 33 twin pregnancies as compared with the results in our previous study, 8 in which weekly daily fetal movement recordings of singleton pregnancies in 127 pregnant women with good outcomes were presented. The means of the daily fetal movement recordings in cases of twins were higher than those in singleton pregnancies. The fetal activity curve of twin pregnancies reached its maximum at the twenty-seventh week with 774 ± 57 (SE) fetal movements and declines until delivery parallel to the curve for singleton pregnancy to 224 ± 32 (SE) fetal movements. The general patterns of both curves were similar, tending to have a bimodal appearance.
Fetal movements in multiple pregnancy
Volume 146 Number 7
791
1500
-SINGLETON CiJ-ooo(lJfWINS
1400
i
1300
!:!
Sf
~
1200
1100
w
...."' zw
1000
~
w
12
10
~
900
...w~
800
0
700
... w
26
28
30
32
34
36
38
40
WEEKS OF PREGNANCY
Fig. I. Daily fetal movement rate (mean ± SE) at different weeks of gestation for twin and singleton pregnancies. Numbers at top or bottom of SE lines depict number of women examined at that particular week.
~w
600
:::;
500
3:
400
i(
""ww
<
300 200
Statistical analysis of the difference between the daily fetal movement rate in multiple and singleton preg· nancies at the same week of gestation was carried out by means of Student's t test. The results obtained are given in Table II. In 5 of 15 weeks, the difference was not found to be statistically significant. In the other 10 weeks, fetal activity showed a significant difference (ranging from p < 0.02 top< 0.5, with the majority of cases having p < 0.5). In Fig. 2, individual daily fetal movement rates for six cases of triplets, one case of quadruplets, and one case of quintuplets are presented for comparison with the mean daily fetal movement recording curves for twins shown in Fig. I. The large majority of values of daily fetal movement rates in cases with three or more fetuses were higher than the corresponding mean values for twin pregnancies.
Comment It was previously demonstrated that a good correlation exists between instrumentally recorded fetal movements and those counted by maternal perception. Thus, the conclusion was that fetal well-being can be reliably monitored by daily maternal measurements of fetal movement rate. 7 • 11 - 14 The results of the present study show that mean fetal activity in twin pregnancies is generally higher than that during singleton pregnancies. However, there is no explanation for the progressive decline in total activity in both cases. The fetal movements in individual
8--C,J TWINS -TRIPlETS <>--(> Q\JADRIJPI.fTS ...._. QUINTUPLETS
100
26
28
30 32 34 36 WEEKS OF PREGNANCY
38
40
Fig. 2. Individual daily fetal movement rate curves for triplet, quadruplet, and quintuplet pregnancies as compared to fetal movement (means) curve of twin pregnancies.
cases of triplets, quadruplets, and quintuplets tended to be even higher than those in twin pregnancies. It is suggested that these findings should be taken into consideration when fetal distress in cases of multiple pregnancy is evaluated by assessment of fetal movements. REFERENCES 1. Pearson, J. F., and Weaver, J. B.: Fetal a<:tivity and fetal well-being. An evaluation, Br. Med. J. 1:1305, 1976. 2. Goodlin, R. C., and Lowe, E. W.: Multiphasic fetal monitoring, AM.]. OBSTET. GYNECOL. 1191341, 1974. 3. Sadovsky, E., and Polishuk, W. Z.: Fetal movements in utero-Review, Obstet. Gynecol. 50:49, 1977. 4. Sadovsky, E., Yaffe, H., and Polishuk, W. Z.: Fetal movement monitoring in normal and pathological pregnancy, Int.]. Gynaecol. Obstet. 12:75, 1974. 5. Wood, C., Gilbert, M., O'Connor, A., et al.: Subjective recording of fetal movements, Br. J. Obstet. Gynaecol. 86:836, 1979. 6. Birger, M., Homburg, R., and Insler, V.: Oinical evaluation of fetal movements, Int. J. Gynaecol. Obstet. 18:377, 1980. 7. Sadovsky, E., Polishuk, W. Z., Mahler, G., et al.: Correlation between electromagnetic recordings and maternal assessment of fetal movement, Lancet 1:1141, 1973.
Samueloff, Evron, and Sadovsky
8. Sadovsky, E.: Fetal movements and fetal health, Semin. Perinatal. 5:131, 1981. 9. Sadovsky, E., and Samueloff, A.: In preparation. 10. Rayburn, W. F.: Antepartum fetal assessment monitoring fetal activity, Clin. Perinatal. 9:231, 1982. 11. Timor-Tritsch, I., Zador, I., Hertz, R. H., and Rosen, M. G.: Classification of fetal movement, AM. J. OsSTET. GYNECOL. 126:70, 1976. 12. Sadovsky, E., Polishuk, W. Z., Yaffe, H., et al.: Fetal
A III(U't 1, 1983 Am . .J Ob,;et Gvnen>l.
movements recorder, use and indications, lnt. J Gynaecol. Obstet. 15:20, 1977. 13. Wood, C., Walters, W. A. W., and Trigg, P.: Methods of recording fetal movement, Br. J ObsteL Gvnat'Coi. 84:561, 1977. 14. Ehrostom, C.: Fetal movement monitoring in normal and high risk pregnancy, Acta Obstet. Gvnecol. Scand. (Suppl.) 80:1, 1979.
Fetal echocardiography III. The diagnosis of cardiac arrhythmias using real-time-directed M-mode ultrasound Greggory R. DeVore, M.D., Bijan Siassi, M.D., and Lawrence D. Platt, M.D. Los Angrle.\, California A technique that makes use of real-time-directed M-mode echocardiography is described in which the fetal heart is evaluated for suspected cardiac arrhythmias. Simultaneous M-mode recording of aortic, mitral, or tricuspid valvular leaflet excursion and/or atrioventricular wall motion defines timing relationships between atrial and ventricular systole. With the use of the techniques described in this report, normal as well as abnormal atrioventricular contractions can be quantitated and cardiac arrhythmias accurately defined. (AM. J. 0BSTET. GYNECOL. 146:792, 1983.)
When auscultation of the fetal heart reveals an abnormally rapid, slow, or irregular rate, the clinician is confronted with the dilemma of how to accurately diagnose the arrhythmia. Unlike the situation during labor, when an electrode can be attached to the presenting part of the fetus to record the electrocardiogram, assessment during the antepartum period is more difficult. The major reason for this is that the methods which have traditionally been used reflect primarily ventricular rate, but not atrioventricular systolic timing relationships which are a prerequisite for accurate diagnosis (Table I). Although a few investigators have reported the use of M-mode ultrasound to diagnose heart rate abnormalities in the fetus,"· 7 the difficulty of accurately locating the cardiac structures through which the M-mode From the Departments a[ Obstetrics and G_vnecology and Pediatrics, University of Southern California Sclwol a[ Medicine, and Women's Hospital, Los Angeles County/University a[ Southern California Medical Center. Supported b_v a grant from The Thrasher Research Fund and The Wright Foundation. Received for publication November I, 1982. Revised Febru.ary 25, 1983. Accepted March 11, 1983. Reprint requests: Greggory R. DeVore, M.D., Women's Hospital, Room 5K22, 1240 North Mission Road, Los Angeles, California 90033.
792
Table I. Antepartum assessment of fetal cardiac arrhythmias Atrial systole Electrocardiogram Alxiominal wall Ultrasound Real time Doppler M-mode
X(?) X
Ventricular systole
A trioventricular
relat:Wnship
Rate
X
X
X X X
X X X
X
beam passes has discouraged many from using this technique. However, with the introduction of realtime-directed M-mode echocardiography,8 it is possible to accurately evaluate the fetal heart for disturbances in cardiac rhythm that occur as early as the second trimester of pregnancy. The present study focused on: (1) the approach using real-time-directed M-mode echocardiography to quantitate normal atrial and ventricular systole, and (2) the diagnosis of disturbances in fetal cardiac rhythm seen in the second and third trimesters of pregnancy. Material and methods
M-mode tracings in this report were obtained from an ongoing study of the fetal heart with the use of
Volume 146 Number 7
conclude that fetal sex is an additional source of variability in measurable maternal serum a-fetoprotein during the second trimester. The underlying cause or causes of this phenomenon remain unknown.
Male Fetuses
60
We acknowledge the support and efforts of the participating physicians in Forsyth and Guilford Counties, without whom this project would not have been possible.
40
20
REFERENCES I. Haddow,]. E., Macri,J. N., and Munson, M.: The amnion
c:
Q)
E
0
0
3: 0 Cii
.Q
E
2.
39.1
100
aoimm
200 3.
Female Fetuses
::J
z
4.
60
5.
6. 7.
36.6
80
160
240
320
400
ng I ml
Fig. 2. Actual distributions of maternal serum a-fetoprotein values between 15 and 19 weeks' gestation in women segregated according to the sex of the fetus. The mean value for each group is indicated by an arrow.
8. 9.
regulates movement of fetally derived alpha fetoprotein into maternal blood, J. Lab. Clin. Med. 94:344, 1979. Haddow, J. E., Kloza, E. M., Knight, G. J., and Smith, D. E.: Relation between maternal weight and serum alpha fetoprotein concentration during the second trimester, Clin. Chern. 27:133, 1981. Crandall, B. F., Schroth, P. 0., and Lebherz, T. B.: Racial differences in maternal serum aipha-fetoprotein ieveis (MSAFP), Am. J. Hum. Genet. 34:85A, 1982. Gardner, S., Burton, B. K., and Johnson, A. M.: Maternal serum alpha fetoprotein screening: A report of the Forsyth County Project, AM.]. OBSTET. GYNECOL. 140:250, 1981. United Kingdom Collaborative Study on alpha fetoprotein in relation to neural tube defects: Maternal serum alpha fetoprotein measurement in antenatal screening for anencephaly and spina bifida in early pregnancy, Lancet 1: 1323, 1977. Box, G. E. P., and Cox, D. R.: An analysis of transformations, J. R. Stat. Soc. %6:2ll, 1964. Iffy, L., .Lavenhar, M., Kaminetzky, H. A., Jonllbloet, P. H., Wmgate, M. B., and Jakobovlts, A.: The eftect of maternal age, parity, fetal sex and season upon early intrauterine development, Int. J. Gynaecol. Obstet. 16:210, 1978. Lardinois, R., Anagnostakis, D., Ortexz, M.A., and Delisle, M.: Human a 1-foetoglobulin during the last trimester of gestation, Clin. Chim. Acta 37:81, 1972. Milunsky, A., Alpert, E., Neff, R. K., and Frigoletro, F. D.: Prenatal diagnosis of neural tube defects. IV. Maternal serum alpha-fetoprotein screening, Obstet. Gynecol. 55: 60, 1980.
Fetal movements in multiple pregnancy A. Satnueloff, S. Evron, and E. Sadovsky Jerusalem, Israel Fetal activity in multiple pregnancies, as expressed by matemal daily fetal movement recordings, was compared with that in singleton pregnancies. It was found that the mean fetal activity in 33 cases of twins, six cases of triplets, one case of quadruplets, and one case of quintuplets was generally higher than that obtained during singleton pregnancies. In most cases, fetal movements of triplets, quadruplets, and quintuplets were even higher than the movement of twins. (AM. J. O!!!TET. GYNEOO-· 146:789, 1983.)
From the High Risk Pregnancy Unit, Department of Obstetrics and Gynecology, Hadassah University Hospital. Received for publicatWn August 24, 1982. Revi5ed December 21, 1982.
Accepted March 11, 1983. Reprint requests: Dr. A. Samueloff, Department of Obstetrics and Gynecolcgy, Hadassah University Hospital, Jerusalem. Israel.
789
790
Samueloff, Evron, and Sadovsky
August I, 1983
Am.
Fetal activity reveals the fetal condition in utero, and daily monitoring of fetal movements provides a good criterion by which to estimate fetal well-being. 1 - 4 Every pregnancy has its own fetal movement rate. 3• 4 The movements are sensed by the mother, whose ability to recognize them is influenced by her character and .education, and by gestational age. 3• 4 Wood and associates5 showed that maternal age, parity, ethnic origin, sex of the fetus, and amniotic fluid volume do not influence the mother's estimate of fetal movement. However, objective assessment of fetal movement showed that the frequency is influenced by parity. 6 It has been suggested that drugs, such as barbiturates and diazepam, reduce fetal movement. 7 An important factor that influences fetal movement is intrauterine hypoxia caused by diminished uteroplacental blood flow, as in preeclamptic toxemia. 3 We previously reported the weekly average of fetal movements in 127 pregnant women with a singleton pregnancy and normal outcome. 8 These patients recorded the number of fetal movements that they perceived during a 30-minute period three times a day. These values were used to estimate the fetal movements over 12 hours, and this 12-hour value was designated daily fetal movements recording. The mean daily fetal movement counts were found to increase from about 200 in the twentieth week of gestation to a maximum of 575 in the thirty-second week and gradually declined thereafter until delivery, with the mean fetal movement rate at the fortieth week being 282. It was suggested in the past that the rate of fetal movement is markedly elevated in cases of multiple pregnancy. The aim of this study was to evaluate the fetal activity in various types of multiple pregnancy.
Material and methods The subjects of this study were 41 pregnant women with multiple fetuses who were hospitalized in the High Risk Pregnancy Unit of Hadassah University Hospital, Jerusalem, Israel, for observation and rest in order to try to delay premature delivery as much as possible. In some cases, /3-mimetic drugs were given. It was previously found 9 • 10 that these drugs do not alter the daily fetal movement recording. An additional 27 cases of multiple pregnancy were discarded during this study because of complications or poor outcome. Table I shows the distribution of the subjects according to the number of fetuses and weeks of pregnancy when the fetal movements were assessed. There was a good outcome in all cases. No perinatal deaths or instances of fetal distress occurred during pregnancy or delivery, and the Apgar scores were at least 7. The women who participated in this study were
J. Obstet. Gynecol.
Table I. Clinical characteristics of the subjects examined (41 multiple pregnancies) No.
offetuses
I
No. of cases
I
of
33 6
Twins Triplets Quadruplets Quintuplets Total
;~ncy 26-40 26-36 27-33 29-34 26-40
l I
41
Table II. Statistical analysis data of differences between daily fetal movement rates in twin and singleton pregnancies at the same week of gestation Weeks of gestation
26 27 28 29 30 31 32 33 34 35 36 37 38 39 40
Twins
N
3 4 3 2 6 9 9 13 14 15 13 11
8 3 2
I Mean I SD 631 774 641 621 497 475 525 584 608 516 527 430 454 285 224
336 115 121 30 116 222 300 314 300 263 258 254 345 126 45
Singleton
N
9 9 11 16 15 16 15 16 26 29 25 17 17 12 10
I Mean I SD 394 493 493 451 443 444 520 477 442 402 450 363 368 280 282
172 176 269 188 195 162 260 232 199 160 238 201 140 254 226
p
<0.5 <0.05 <0.5 <0.5
NS NS NS <0.5 <0.02 <0.1 <0.5 <0.5 <0.5
NS NS
asked to assess the fetal movements they felt during a period of 30 minutes, after meals while lying in bed on their side. The measurements were made three times a day, in the morning, at noon, and in the evening. The number of fetal movements was calculated for 12 hours, thereby obtaining the daily fetal movement recording. The subjects were instructed to count a sequence of fetal movements as a single movement.
Results Fig. 1 shows the values of daily fetal movement rate (means ± SE) according to the week of gestation in 33 twin pregnancies as compared with the results in our previous study, 8 in which weekly daily fetal movement recordings of singleton pregnancies in 127 pregnant women with good outcomes were presented. The means of the daily fetal movement recordings in cases of twins were higher than those in singleton pregnancies. The fetal activity curve of twin pregnancies reached its maximum at the twenty-seventh week with 774 ± 57 (SE) fetal movements and declines until delivery parallel to the curve for singleton pregnancy to 224 ± 32 (SE) fetal movements. The general patterns of both curves were similar, tending to have a bimodal appearance.
Fetal movements in multiple pregnancy
Volume 146 Number 7
791
1500
-SINGLETON CiJ-ooo(lJfWINS
1400
i
1300
!:!
Sf
~
1200
1100
w
...."' zw
1000
~
w
12
10
~
900
...w~
800
0
700
... w
26
28
30
32
34
36
38
40
WEEKS OF PREGNANCY
Fig. I. Daily fetal movement rate (mean ± SE) at different weeks of gestation for twin and singleton pregnancies. Numbers at top or bottom of SE lines depict number of women examined at that particular week.
~w
600
:::;
500
3:
400
i(
""ww
<
300 200
Statistical analysis of the difference between the daily fetal movement rate in multiple and singleton preg· nancies at the same week of gestation was carried out by means of Student's t test. The results obtained are given in Table II. In 5 of 15 weeks, the difference was not found to be statistically significant. In the other 10 weeks, fetal activity showed a significant difference (ranging from p < 0.02 top< 0.5, with the majority of cases having p < 0.5). In Fig. 2, individual daily fetal movement rates for six cases of triplets, one case of quadruplets, and one case of quintuplets are presented for comparison with the mean daily fetal movement recording curves for twins shown in Fig. I. The large majority of values of daily fetal movement rates in cases with three or more fetuses were higher than the corresponding mean values for twin pregnancies.
Comment It was previously demonstrated that a good correlation exists between instrumentally recorded fetal movements and those counted by maternal perception. Thus, the conclusion was that fetal well-being can be reliably monitored by daily maternal measurements of fetal movement rate. 7 • 11 - 14 The results of the present study show that mean fetal activity in twin pregnancies is generally higher than that during singleton pregnancies. However, there is no explanation for the progressive decline in total activity in both cases. The fetal movements in individual
8--C,J TWINS -TRIPlETS <>--(> Q\JADRIJPI.fTS ...._. QUINTUPLETS
100
26
28
30 32 34 36 WEEKS OF PREGNANCY
38
40
Fig. 2. Individual daily fetal movement rate curves for triplet, quadruplet, and quintuplet pregnancies as compared to fetal movement (means) curve of twin pregnancies.
cases of triplets, quadruplets, and quintuplets tended to be even higher than those in twin pregnancies. It is suggested that these findings should be taken into consideration when fetal distress in cases of multiple pregnancy is evaluated by assessment of fetal movements. REFERENCES 1. Pearson, J. F., and Weaver, J. B.: Fetal a<:tivity and fetal well-being. An evaluation, Br. Med. J. 1:1305, 1976. 2. Goodlin, R. C., and Lowe, E. W.: Multiphasic fetal monitoring, AM.]. OBSTET. GYNECOL. 1191341, 1974. 3. Sadovsky, E., and Polishuk, W. Z.: Fetal movements in utero-Review, Obstet. Gynecol. 50:49, 1977. 4. Sadovsky, E., Yaffe, H., and Polishuk, W. Z.: Fetal movement monitoring in normal and pathological pregnancy, Int.]. Gynaecol. Obstet. 12:75, 1974. 5. Wood, C., Gilbert, M., O'Connor, A., et al.: Subjective recording of fetal movements, Br. J. Obstet. Gynaecol. 86:836, 1979. 6. Birger, M., Homburg, R., and Insler, V.: Oinical evaluation of fetal movements, Int. J. Gynaecol. Obstet. 18:377, 1980. 7. Sadovsky, E., Polishuk, W. Z., Mahler, G., et al.: Correlation between electromagnetic recordings and maternal assessment of fetal movement, Lancet 1:1141, 1973.
Samueloff, Evron, and Sadovsky
8. Sadovsky, E.: Fetal movements and fetal health, Semin. Perinatal. 5:131, 1981. 9. Sadovsky, E., and Samueloff, A.: In preparation. 10. Rayburn, W. F.: Antepartum fetal assessment monitoring fetal activity, Clin. Perinatal. 9:231, 1982. 11. Timor-Tritsch, I., Zador, I., Hertz, R. H., and Rosen, M. G.: Classification of fetal movement, AM. J. OsSTET. GYNECOL. 126:70, 1976. 12. Sadovsky, E., Polishuk, W. Z., Yaffe, H., et al.: Fetal
A III(U't 1, 1983 Am . .J Ob,;et Gvnen>l.
movements recorder, use and indications, lnt. J Gynaecol. Obstet. 15:20, 1977. 13. Wood, C., Walters, W. A. W., and Trigg, P.: Methods of recording fetal movement, Br. J ObsteL Gvnat'Coi. 84:561, 1977. 14. Ehrostom, C.: Fetal movement monitoring in normal and high risk pregnancy, Acta Obstet. Gvnecol. Scand. (Suppl.) 80:1, 1979.
Fetal echocardiography III. The diagnosis of cardiac arrhythmias using real-time-directed M-mode ultrasound Greggory R. DeVore, M.D., Bijan Siassi, M.D., and Lawrence D. Platt, M.D. Los Angrle.\, California A technique that makes use of real-time-directed M-mode echocardiography is described in which the fetal heart is evaluated for suspected cardiac arrhythmias. Simultaneous M-mode recording of aortic, mitral, or tricuspid valvular leaflet excursion and/or atrioventricular wall motion defines timing relationships between atrial and ventricular systole. With the use of the techniques described in this report, normal as well as abnormal atrioventricular contractions can be quantitated and cardiac arrhythmias accurately defined. (AM. J. 0BSTET. GYNECOL. 146:792, 1983.)
When auscultation of the fetal heart reveals an abnormally rapid, slow, or irregular rate, the clinician is confronted with the dilemma of how to accurately diagnose the arrhythmia. Unlike the situation during labor, when an electrode can be attached to the presenting part of the fetus to record the electrocardiogram, assessment during the antepartum period is more difficult. The major reason for this is that the methods which have traditionally been used reflect primarily ventricular rate, but not atrioventricular systolic timing relationships which are a prerequisite for accurate diagnosis (Table I). Although a few investigators have reported the use of M-mode ultrasound to diagnose heart rate abnormalities in the fetus,"· 7 the difficulty of accurately locating the cardiac structures through which the M-mode From the Departments a[ Obstetrics and G_vnecology and Pediatrics, University of Southern California Sclwol a[ Medicine, and Women's Hospital, Los Angeles County/University a[ Southern California Medical Center. Supported b_v a grant from The Thrasher Research Fund and The Wright Foundation. Received for publication November I, 1982. Revised Febru.ary 25, 1983. Accepted March 11, 1983. Reprint requests: Greggory R. DeVore, M.D., Women's Hospital, Room 5K22, 1240 North Mission Road, Los Angeles, California 90033.
792
Table I. Antepartum assessment of fetal cardiac arrhythmias Atrial systole Electrocardiogram Alxiominal wall Ultrasound Real time Doppler M-mode
X(?) X
Ventricular systole
A trioventricular
relat:Wnship
Rate
X
X
X X X
X X X
X
beam passes has discouraged many from using this technique. However, with the introduction of realtime-directed M-mode echocardiography,8 it is possible to accurately evaluate the fetal heart for disturbances in cardiac rhythm that occur as early as the second trimester of pregnancy. The present study focused on: (1) the approach using real-time-directed M-mode echocardiography to quantitate normal atrial and ventricular systole, and (2) the diagnosis of disturbances in fetal cardiac rhythm seen in the second and third trimesters of pregnancy. Material and methods
M-mode tracings in this report were obtained from an ongoing study of the fetal heart with the use of