- Email: [email protected]
Outcome of twin gestations complicated by a single anomalous fetus
Citationsfrom
the literature /International
Journal of Gynecology & Obstetrics 55 (1996) 313-321
ment to the trial was stopped early (November, 1995) by the trial steering committee on the advice of the independent data-monitoring committee, because the data accumulated showed a clear advantage with ECMO. 124 children were enrolled before December, 1994; those who survived to 1 year of age have undergone neurological assessmentat that age (by one of three developmental paediatricians unaware of treatment allocation). Findings: Overall, 81 (44%) infants died before leaving hospital, and two are known to have died later. Death rates differed between the two trial groups; 30 of 93 infants allocated ECMO died compared with 54 of 92 allocated conventional care. The relative risk was 0.55 (95% CI 0.39-0.77; P= O.OOOS), which is equivalent to one extra survivor for every 3-4 infants allocated ECMO. The difference in survival applied irrespective of the primaty diagnosis, disease severity, and type of referral centre. The benefit of ECMO was also found for the primary outcome measure of death or disability at 1 year (among 124 children enrolled before December, 1994). One child in each group has severe disability (overall Griffiths’ developmental quotient < SO, or untestable), and 16 (ten ECMO, six conventional management) have impairments with a lesser degree of disability. Interpretation: These preliminary results demonstrate the clinical effectiveness of a well-staffed and organised neonatal ECMO service. ECMO support should be actively considered for neonates with severe but potentially reversible respiratory failure. The effects of S-nitrosoglutathione on platelet activation, hypertension, and uterine and fetal Doppler in severe preeclampsia Lees C.; Langford E.; Brown AS.; De Belder A.; Pickles A.; Martin J.F.; Campbell S. GBR
OBSTET GYNECOL 1996 88/l (14-19) Objective: To determine the effects of the platelet-specific nitric oxide donor S-nitrosoglutathione on women with severe preeclampsia. Methods: Ten women with severe preeclampsia or preeclampsia with severe fetal compromise at 21-33 weeks gestation each received a 60-90-min intravenous infusion of 50-250 Pbpg/min of S-nitrosoglutathione. Each was hypertensive, despite conventional oral antihypertensive therapy in eight. Maternal blood pressure, heart rate, platelet activation, uterine artery, and fetal Doppler indices were measured during the infusion. Results: A dose-dependent reduction in mean arterial pressure from 125 mmHg (95% confidence interval (Cl) 117-133) to 103.5 (95% CI 97-111) (P < 0.005) and an increase in pulse rate from 73.7 beats per min (95% CI 64.3-84.5) to 89.1(95% Cl 81.2-97.8) (P < 0.02) was observed during the infusion. Mean uterine artery resistance index fell from 0.76 (95% CI 0.73-0.81) to 0.70 (95% CI 0.65-0.75) (P < 0.009). Platelet activation measured by P-selectin expression was reduced from 3.02% (95% CI 2.09-4.36) to 1.22% (95% CI 0.94-1.58) (P < 0.01). Fetal Doppler indices (umhilical artery, middle cerebral artery, and thoracic aorta) showed no significant changes during the infusion. Conclusion: S-nitrosoglutathione infusion reduced maternal mean
315
arterial pressure, platelet activation, and uterine artery resistance without further compromising fetal Doppler indices. This study suggests that platelet-specific nitric oxide donors may prove beneficial in the management of severe preeclampsia. Obstetrical factors and the transmission of human immunodeficiency virus type 1 from mother to child Landesman S.H.; Kalish L.A.; Burns D.N.; Minkoff H.; Fox H.E.; Zorrilla C.; Garcia P.; Fowler M.G.; Mofenson L.; Tromala R. USA
N ENGL J MED 1996 334/25 (1617-1623) Background. A substantial proportion of perinatally acquired infections with the human immunodeficiency virus type 1 (HIV-l) occur at or near delivery, which suggests that obstetrical factors may have an important influence on transmission. We evaluated the relation of such factors and other variables to the perinatal transmission of HIV-l. Methods. The Women and Infants transmission Study is a prospective, observational study of HIV-l-infected women who were enrolled during pregnancy and followed with their infants for 3 years after delivery. We studied obstetrical, clinical, immunologic, and virologic data on 525 women who delivered live singleton infants whose HIV-l-infection status was known as of August 31, 1994. Results. Among mothers with membranes that ruptured more than 4 h before delivery, the rate of transmission of HIV-l to the infants was ZS%, as compared with 14% among mothers with membranes that ruptured 4 h or less before delivery. In a multivariate analysis, the presence of ruptured membranes for more than 4 h nearly doubled the risk of transmission (odds ratio, 1.82; 95% confidence interval, 1.10-3.00; P= 0.02), regardless of the mode of delivery. The other maternal factors independently associated with transmission were illicit-drug use during pregnancy (odds ratio, 1.90; 95% confidence interval, 1.14-3.16; P = O.Ol), low antenatal Cd4 + lymphocyte count (< 29% of total lymphocytes) (odds ratio, 2.82; 1.67-4.76; P < O.OOl), and birth weight < 2500 g (odds ratio, I .86; 1.03-3.34; P = 0.04). Conclusions. The risk of transmission of HIV-l from mother to infant increases when the fetal membranes rupture more than 4 h before delivery. Outcome of twin gestations complicated by a single anomalous fetus Malone F.D.; Craig0 S.D.; Chelmow D.; D’Alton M.E. USA
OBSTET GYNECOL 1996 88/l (l-5) Objective: To compare the outcome of twin gestations complicated by a single anomalous fetus with twin gestations with no fetal anomalies. Methods: The study included all patients with twin gestations diagnosed with a fetal anomaly in one fetus during 1990-1994, and excluded twin gestations with anomalies in both fetuses. The control twin group was composed of all other normal twin pregnancies followed and delivered at our center in the preceding 2 years. Results: We reviewed 24 twin
Citations from the litemtwe /IntemationalJotrmal
316
gestations with at least one anomalous fetus. Five cases were excluded because of anomalies in both fetuses, and a further five pregnancies had selective termination or termination of the entire pregnancy. There were I4 ongoing twin pregnancies with one anomalous fetus, and their median gestational age at diagnosis was I8 weeks (range 16-20). All twin anomalies were correctly diagnosed antenatally. Gestational age at delivery and birth weight were significantly lower for twins complicated by an anomaly compared with control twins (P = 0.008 and P = 0.001. respectively). The cesarean delivery and perinatal mortality rates of twin pregnancies with anomalies were significantly higher than those of normal twins (P = 0.01 and P < 0.001, respectively). Conclusion: The presence of a single anomalous fetus in a twin gestation significantly increases the risk of preterm delivery compared with non-anomalous twin gestations.
Sonographic prediction diabetic mothers Cohen T.
8.; Penning
of shoulder
S.; Major
C.; Ansley
dystocia
in infants
D.; Port0
of
M.; Garite
USA OBSTET GYNECOL 1996 88/l (10-13) Objective: To determine if the difference between the abdominal diameter and biparietal diameter (AD-BPD difference), as measured by ultrasound examination, predicts shoulder dystocia in borderline macrosomic infants of diabetic mothers. Methods: A retrospective study was performed of births occurring from January 1990 through June 1995. Eligibility requirements included diabetic pregnancy, ultrasound examination within 2 weeks of delivery, estimated fetal weight of 3800-4200 g, and vaginal delivery. The mean AD-BPD difference was compared in normal deliveries and those complicated by shoulder dystocia, using the Student t test and by multiple regression analysis. A receiver operating characteristic cmve was generated to determine if an AD-BPD cutoff value could be used clinically to predict shoulder dystocia. Results: Thirty-one patients, six with dystocia, were eligible for the study. The mean AD-BPD differences for those with and without shoulder dystocia were 3.1 and 2.6 cm, respectively, a statistically significant difference (P = 0.05). Comparing the groups with and without shoulder dystocia, no significant differences could be found in mean age, parity, weight, birth weight, or gestational age. Shoulder dystocia occurred in 6 of 20 patients (30%) in whom the AD-BPD difference was at least 2.6 cm but in none of I1 patients in whom it was less than 2.6 cm, also a statistically significant difference (P = 0.05). Conclusion: The AD-BPD difference was greater in borderline macrosomic fetuses of diabetic mothers who experienced shoulder dystocia than in those who had uncomplicated vaginal deliveries. Applying an AD-BPD cutoff value of 2.6 cm to this population prospectively would have provided excellent sensitivity, specificity, and predictive value in identifying those fetuses at high risk for birth injury.
Inadequacy of rapid immunoassays for intrapartum of group B streptococcal carriers
detection
of Gynecology d Obstetrics 55 (1996) 313-321 Baker C.J. USA OBSTET GYNECOL 1996 88/l (51-55) Objective: To determine the accuracy of two currently used immunoassays and a newly developed optical immunoassay for rapid intrapartum detection of group B streptococcal colonization compared with culture methods. Methods: Rayon-tipped swabs were used to collect specimens from the distal vagina of 502 women at admission for labor or rupture of membranes. Four tests were performed on specimens from the first I97 patients: culture in selective broth medium, semiquantitative culture on blood agar medium, and ICON Strep B and Quidel Group B Strep Test enzyme immunoassays. For the remaining 305 women, a fifth test, Strep B OIA, a newly developed optical immunoassay, was also performed. Results: The prevalence of group B streptococcal vaginal colonization was 25.1% by selective broth medium and 77.3% when swabs were plated directly onto blood agar medium, giving the latter method a sensitivity of 69%. When compared with selective broth medium results, the sensitivities of the rapid immunoassays were 12% (Quidel), 15% (ICON), and 37% (Strep B OIA). These values rose to 16% (Quidel), 21% (ICON), and 53% (Strep B OIA) when compared with non-selective blood agar medium results. For women with heavy group B streptococcal colonization (more than lo6 colony forming units/ml), the sensitivities were 36% (Quidel), 46% (ICON), and 100% (Strep B OIA). Specificities for all assays were high (9&X-100%), but variability was found in positive (79-100%) and negative (7785%) predictive values. Conclusion: Although Strep B OIA reliably detects women with heavy group B streptococcal colonization and is more sensitive than either the ICON or Quidel enzyme immunoassays, none of these rapid assays is sufficiently accurate for routine use in the intrapartum detection of women colonized with group B streptococcus.
FERTILITY
AND
STERILITY
Reinsemination of one-day-old plasmic sperm injection Lundin
K.; Sjogren
A.; Hamberger
oocytes by use of intracytoL.
SWE FERTIL STERIL 1996 66/l (118-121) Objective: To evaluate the possible advantages of reinseminating oocytes by use of intracytoplasmic sperm injection (ICSII. Design: Clinical study. Setting: In vitro fertilization unit with research facilities. Patients; Fifty-seven couples who were part of our regular IVF program. Interventions: Non-fertilized oocytes from IVF cycles with no or very low fertilization were microinjected with spermatozoa approximately 25 h after oocyte pick-up. Main Outcome Measures: Fertilization and pregnancy rates. Results: A mean fertilization rate of 46.5% was obtained when reinseminating the oocytes on day 2 using the ICSI procedure. Of 57 cycles with completely or almost completely failed fertilization, 29 patients received ET after reinsemination by ICSI. Two of these transfers resulted in pregnancies (6.9% per ET) and two healthy babies were born.
the literature /International
Journal of Gynecology & Obstetrics 55 (1996) 313-321
ment to the trial was stopped early (November, 1995) by the trial steering committee on the advice of the independent data-monitoring committee, because the data accumulated showed a clear advantage with ECMO. 124 children were enrolled before December, 1994; those who survived to 1 year of age have undergone neurological assessmentat that age (by one of three developmental paediatricians unaware of treatment allocation). Findings: Overall, 81 (44%) infants died before leaving hospital, and two are known to have died later. Death rates differed between the two trial groups; 30 of 93 infants allocated ECMO died compared with 54 of 92 allocated conventional care. The relative risk was 0.55 (95% CI 0.39-0.77; P= O.OOOS), which is equivalent to one extra survivor for every 3-4 infants allocated ECMO. The difference in survival applied irrespective of the primaty diagnosis, disease severity, and type of referral centre. The benefit of ECMO was also found for the primary outcome measure of death or disability at 1 year (among 124 children enrolled before December, 1994). One child in each group has severe disability (overall Griffiths’ developmental quotient < SO, or untestable), and 16 (ten ECMO, six conventional management) have impairments with a lesser degree of disability. Interpretation: These preliminary results demonstrate the clinical effectiveness of a well-staffed and organised neonatal ECMO service. ECMO support should be actively considered for neonates with severe but potentially reversible respiratory failure. The effects of S-nitrosoglutathione on platelet activation, hypertension, and uterine and fetal Doppler in severe preeclampsia Lees C.; Langford E.; Brown AS.; De Belder A.; Pickles A.; Martin J.F.; Campbell S. GBR
OBSTET GYNECOL 1996 88/l (14-19) Objective: To determine the effects of the platelet-specific nitric oxide donor S-nitrosoglutathione on women with severe preeclampsia. Methods: Ten women with severe preeclampsia or preeclampsia with severe fetal compromise at 21-33 weeks gestation each received a 60-90-min intravenous infusion of 50-250 Pbpg/min of S-nitrosoglutathione. Each was hypertensive, despite conventional oral antihypertensive therapy in eight. Maternal blood pressure, heart rate, platelet activation, uterine artery, and fetal Doppler indices were measured during the infusion. Results: A dose-dependent reduction in mean arterial pressure from 125 mmHg (95% confidence interval (Cl) 117-133) to 103.5 (95% CI 97-111) (P < 0.005) and an increase in pulse rate from 73.7 beats per min (95% CI 64.3-84.5) to 89.1(95% Cl 81.2-97.8) (P < 0.02) was observed during the infusion. Mean uterine artery resistance index fell from 0.76 (95% CI 0.73-0.81) to 0.70 (95% CI 0.65-0.75) (P < 0.009). Platelet activation measured by P-selectin expression was reduced from 3.02% (95% CI 2.09-4.36) to 1.22% (95% CI 0.94-1.58) (P < 0.01). Fetal Doppler indices (umhilical artery, middle cerebral artery, and thoracic aorta) showed no significant changes during the infusion. Conclusion: S-nitrosoglutathione infusion reduced maternal mean
315
arterial pressure, platelet activation, and uterine artery resistance without further compromising fetal Doppler indices. This study suggests that platelet-specific nitric oxide donors may prove beneficial in the management of severe preeclampsia. Obstetrical factors and the transmission of human immunodeficiency virus type 1 from mother to child Landesman S.H.; Kalish L.A.; Burns D.N.; Minkoff H.; Fox H.E.; Zorrilla C.; Garcia P.; Fowler M.G.; Mofenson L.; Tromala R. USA
N ENGL J MED 1996 334/25 (1617-1623) Background. A substantial proportion of perinatally acquired infections with the human immunodeficiency virus type 1 (HIV-l) occur at or near delivery, which suggests that obstetrical factors may have an important influence on transmission. We evaluated the relation of such factors and other variables to the perinatal transmission of HIV-l. Methods. The Women and Infants transmission Study is a prospective, observational study of HIV-l-infected women who were enrolled during pregnancy and followed with their infants for 3 years after delivery. We studied obstetrical, clinical, immunologic, and virologic data on 525 women who delivered live singleton infants whose HIV-l-infection status was known as of August 31, 1994. Results. Among mothers with membranes that ruptured more than 4 h before delivery, the rate of transmission of HIV-l to the infants was ZS%, as compared with 14% among mothers with membranes that ruptured 4 h or less before delivery. In a multivariate analysis, the presence of ruptured membranes for more than 4 h nearly doubled the risk of transmission (odds ratio, 1.82; 95% confidence interval, 1.10-3.00; P= 0.02), regardless of the mode of delivery. The other maternal factors independently associated with transmission were illicit-drug use during pregnancy (odds ratio, 1.90; 95% confidence interval, 1.14-3.16; P = O.Ol), low antenatal Cd4 + lymphocyte count (< 29% of total lymphocytes) (odds ratio, 2.82; 1.67-4.76; P < O.OOl), and birth weight < 2500 g (odds ratio, I .86; 1.03-3.34; P = 0.04). Conclusions. The risk of transmission of HIV-l from mother to infant increases when the fetal membranes rupture more than 4 h before delivery. Outcome of twin gestations complicated by a single anomalous fetus Malone F.D.; Craig0 S.D.; Chelmow D.; D’Alton M.E. USA
OBSTET GYNECOL 1996 88/l (l-5) Objective: To compare the outcome of twin gestations complicated by a single anomalous fetus with twin gestations with no fetal anomalies. Methods: The study included all patients with twin gestations diagnosed with a fetal anomaly in one fetus during 1990-1994, and excluded twin gestations with anomalies in both fetuses. The control twin group was composed of all other normal twin pregnancies followed and delivered at our center in the preceding 2 years. Results: We reviewed 24 twin
Citations from the litemtwe /IntemationalJotrmal
316
gestations with at least one anomalous fetus. Five cases were excluded because of anomalies in both fetuses, and a further five pregnancies had selective termination or termination of the entire pregnancy. There were I4 ongoing twin pregnancies with one anomalous fetus, and their median gestational age at diagnosis was I8 weeks (range 16-20). All twin anomalies were correctly diagnosed antenatally. Gestational age at delivery and birth weight were significantly lower for twins complicated by an anomaly compared with control twins (P = 0.008 and P = 0.001. respectively). The cesarean delivery and perinatal mortality rates of twin pregnancies with anomalies were significantly higher than those of normal twins (P = 0.01 and P < 0.001, respectively). Conclusion: The presence of a single anomalous fetus in a twin gestation significantly increases the risk of preterm delivery compared with non-anomalous twin gestations.
Sonographic prediction diabetic mothers Cohen T.
8.; Penning
of shoulder
S.; Major
C.; Ansley
dystocia
in infants
D.; Port0
of
M.; Garite
USA OBSTET GYNECOL 1996 88/l (10-13) Objective: To determine if the difference between the abdominal diameter and biparietal diameter (AD-BPD difference), as measured by ultrasound examination, predicts shoulder dystocia in borderline macrosomic infants of diabetic mothers. Methods: A retrospective study was performed of births occurring from January 1990 through June 1995. Eligibility requirements included diabetic pregnancy, ultrasound examination within 2 weeks of delivery, estimated fetal weight of 3800-4200 g, and vaginal delivery. The mean AD-BPD difference was compared in normal deliveries and those complicated by shoulder dystocia, using the Student t test and by multiple regression analysis. A receiver operating characteristic cmve was generated to determine if an AD-BPD cutoff value could be used clinically to predict shoulder dystocia. Results: Thirty-one patients, six with dystocia, were eligible for the study. The mean AD-BPD differences for those with and without shoulder dystocia were 3.1 and 2.6 cm, respectively, a statistically significant difference (P = 0.05). Comparing the groups with and without shoulder dystocia, no significant differences could be found in mean age, parity, weight, birth weight, or gestational age. Shoulder dystocia occurred in 6 of 20 patients (30%) in whom the AD-BPD difference was at least 2.6 cm but in none of I1 patients in whom it was less than 2.6 cm, also a statistically significant difference (P = 0.05). Conclusion: The AD-BPD difference was greater in borderline macrosomic fetuses of diabetic mothers who experienced shoulder dystocia than in those who had uncomplicated vaginal deliveries. Applying an AD-BPD cutoff value of 2.6 cm to this population prospectively would have provided excellent sensitivity, specificity, and predictive value in identifying those fetuses at high risk for birth injury.
Inadequacy of rapid immunoassays for intrapartum of group B streptococcal carriers
detection
of Gynecology d Obstetrics 55 (1996) 313-321 Baker C.J. USA OBSTET GYNECOL 1996 88/l (51-55) Objective: To determine the accuracy of two currently used immunoassays and a newly developed optical immunoassay for rapid intrapartum detection of group B streptococcal colonization compared with culture methods. Methods: Rayon-tipped swabs were used to collect specimens from the distal vagina of 502 women at admission for labor or rupture of membranes. Four tests were performed on specimens from the first I97 patients: culture in selective broth medium, semiquantitative culture on blood agar medium, and ICON Strep B and Quidel Group B Strep Test enzyme immunoassays. For the remaining 305 women, a fifth test, Strep B OIA, a newly developed optical immunoassay, was also performed. Results: The prevalence of group B streptococcal vaginal colonization was 25.1% by selective broth medium and 77.3% when swabs were plated directly onto blood agar medium, giving the latter method a sensitivity of 69%. When compared with selective broth medium results, the sensitivities of the rapid immunoassays were 12% (Quidel), 15% (ICON), and 37% (Strep B OIA). These values rose to 16% (Quidel), 21% (ICON), and 53% (Strep B OIA) when compared with non-selective blood agar medium results. For women with heavy group B streptococcal colonization (more than lo6 colony forming units/ml), the sensitivities were 36% (Quidel), 46% (ICON), and 100% (Strep B OIA). Specificities for all assays were high (9&X-100%), but variability was found in positive (79-100%) and negative (7785%) predictive values. Conclusion: Although Strep B OIA reliably detects women with heavy group B streptococcal colonization and is more sensitive than either the ICON or Quidel enzyme immunoassays, none of these rapid assays is sufficiently accurate for routine use in the intrapartum detection of women colonized with group B streptococcus.
FERTILITY
AND
STERILITY
Reinsemination of one-day-old plasmic sperm injection Lundin
K.; Sjogren
A.; Hamberger
oocytes by use of intracytoL.
SWE FERTIL STERIL 1996 66/l (118-121) Objective: To evaluate the possible advantages of reinseminating oocytes by use of intracytoplasmic sperm injection (ICSII. Design: Clinical study. Setting: In vitro fertilization unit with research facilities. Patients; Fifty-seven couples who were part of our regular IVF program. Interventions: Non-fertilized oocytes from IVF cycles with no or very low fertilization were microinjected with spermatozoa approximately 25 h after oocyte pick-up. Main Outcome Measures: Fertilization and pregnancy rates. Results: A mean fertilization rate of 46.5% was obtained when reinseminating the oocytes on day 2 using the ICSI procedure. Of 57 cycles with completely or almost completely failed fertilization, 29 patients received ET after reinsemination by ICSI. Two of these transfers resulted in pregnancies (6.9% per ET) and two healthy babies were born.