- Email: [email protected]
Ultrasonic placental grading and fetal pulmonary maturity
11 0 Communications in brief
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the adult population makes the likelihood of its presence in transfusion blood rare. However, evidence of a fetomaternal transfusion out of proportion to estimated fetal blood volume in a patient with a history of recent blood transfusion may indicate the need to evaluate the transfused blood for the presence of persistent fetal hemoglobin. REFERENCES I. The Selective Use of Rho l(D) Immune Globulin (RLI G), A.merican College of Obstetricians and Gynecologists Technical Bulletin No. 61, March, 1981. 2. Pritchard, J. A., and MacDonald, P. C., editors: Williams Obstetrics, ed. 16, New York, 1980, Appleton-CenturyCrofts, chap. H, p. 185.
Ultrasonic placental grading and fetal pulmonary maturity R. VVILLIANf QUINLAN, !v1.D. AMELIA C. CRUZ, M.D.
Department of Obstetrics and Gynecology, University of Florida. College of Medicine, Gainesville, Florida
appearance of the placenta have been correlated to its maturation and to fetal pulmonary maturity. Crannum and associates 1 and Hobbins 2 have described a grading system based upon placental sonographic characteristics. In one study, 1 no patient with a Grade III placenta was found to have an amniotic fluid lecithin/sphingomyelin (LIS) ratio of less than 2: I. The authors also noted that, in complicated pregnancies, this placental change could be seen as early as 33 weeks' gestation. They have proposed that. if this relationship of placental maturation and fetal pulmonary maturity were to hold true, it might be possible to circumvent the need to obtain amniotic Huid for determination of fetal pulmonary maturity in patients in whom the performance of amniocentesis might be dangerous or contraindicated. In order to further investigate the correlation between the grading of placental maturity and fetal pulmonary maturity, a prospective study was established at the University of Florida. Pregnancies that required evaluation of amniotic fluid for fetal lung maturation were also evaluated by ultrasound for placental changes. Patients with pregnancy complications of diabetes mellitus, hypertension, Rh sensitization, or previous cesarean section were included. The placenta was evaluated both by static and real-time ultrasound, and two independent observers graded the placenta according to the scheme of Grannum and associates prior to the perforCHANGES IN ULTRASONIC
Reprint requests: Dr. R. William Quinlan, Department of Obstetrics and Gynecology, University of Florida, College of Medicine, Box J-294, JHMHC, Gainesville, Florida 32610. 0002-9378/82/010110+02$00.20/0 © 1982 The C. V. Mosby Co.
Fig. 1. :\nterior placenta \'/ith Grade ! l! l hLtnge~. iucludin~ calcification, centrilobular sonolucencv, ,md 'eptatiun ro tht· basal plate.
mance of amniocentesis. A pulmonan prof tie. including LIS ratio and detection ofphosphatidylglyn:T•Jl. wa~ performed on the Huid obtained. :'\o patients underwent deli\ery unless the LIS ratio was greater than :! : l and phosphatidylglvcerol was present in the amnioti< Huid, unless deliYery was obstetrically indicated beuusc of maternal complications. Among the patients studiul to date. three ha\C demonstrated all the charaneri,tin of a Grade III placenta bv the cla,sificat i.. n o! Gra 1!lll!IIl and co-workers but, on repeated determinations. had ;m immature LIS ratio that indicated ~~~~ absence ol fetal pulmonary maturity. One of the paticnr- is reported on here, by \\ay of illmtration. The patient was a 22-year-old nullipar<>th black 1\0t!l. at which time the placenta was again evaluated by two independent examiners as being Grade III (Fig. 1). The amniotic thud LIS ratio was 1.6: l and phosphatidylglyceml was absent. \pproximately I week later. because of a worsening maternal condition, amniocentesis was repeated. At this time the placenta was again evaluated sonographicalh as being Cradt· Ill, the LIS had returned to 1.55: l, and phosphatidvlglvceml W
Communications in brief
Volume 142 Number I
Labor was induced and the patient was delivered of a female infant who weighed 2,260 gm and had Apgar scores of 9 and 8 at 1 and 5 minutes, respectively. The infant did not exhibit any signs of respiratory distress in the neonatal period. Gross examination of the placenta, which weighed 400 gm, revealed gritty calcifications and multiple small placental infarcts. During the postpartum period, the mother required medication to control persistent hypertension.
Ultrasonic grading of placental maturation has been advanced by Grannum and associates 1 as a potential method for determining fetal pulmonary maturity in those pregnancies in which amniocentesis would be difficult or hazardous to the patient or fetus. In evaluating high-risk pregnancies complicated by hypertension, Rh isoimmunization, or diabetes, we have found that this method is not infallible in predicting fetal pulmonary maturity. We have observed an instance of a Grade III placenta with all the characteristic findings of calcification, interruptions of the chorionic plate to the basal layer, and sonolucent fallout areas, in a pregnancy in which there was an immature LIS ratio over a 3-week period. For this reason, placental grading by ultrasound cannot be expected to predict fetal pulmonary maturity in all instances of complicated pregnancy. Further investigation in a prospective manner will be necessary in order to validate the use of placental sonographic appearance in predicting fetal pulmonary maturity in the medically complicated pregnancy. We will continue our study along these lines 10 predict the accuracy of this clinical test.
Table I. Blood viscosity and its major determinants throughout normal pregnancy
No. of subjects Blood viscosity (centipoise) Mean SD Hematocrit Mean
SD Plasma fibrinogen (gm/L) Mean
SD Plasma viscosity (centipoise) Mean
SD Erythrocyte deformability index Mean
SD
30
I. Grannum, P. A. T., Berkowitz, R. L., and Hobbins, J. C.: The LIS changes in the maturing placenta and their relation to fetal pulmonic maturity. AM. J. 0BSTET. GvNECOL 133:91.5, 1979. 2. Hobbins,]. C.: Management decisions in OB, in Sabbagha, R. E .. editor: Diagnostic Ultrasound Applied to Ob & Gyn, Hagerstown, 1980, Harper& Row, Publishers, pp. 135-136.
Preeclampsia-A hyperviscosity syndrome PETER C. BUCHAN, B.Sc., M.D., M .R.C.O.G.
Department of Obstetrics arul GynMcology, St. james's University Hospital, Leeds, Englarul PREECLAMPSIA IS ASSOCIATED with fetal intrauterine growth retardation resulting from reduced intervillous placental blood flow. 1 The limitation of intervillous flow is attributed to narrowing of the vessel lumina by atherosclerosis: however, blood hypenis-
Reprint requests: Peter C. Buchan, Department of Obstetrics and Gynaecology, St. James University Hospital, Leeds, England LS9 7TF. 0002-9378/82/010111 +02$00.20/0 © 1982 The C. V. Iv1osby Cu.
30
30
30
30
8.83 1.48
7.72 1.62
8.92 1.54
9.56 1.60
9.34 1.71
0.346 0.020
0.342 0.018
0.348 0.019
3.358 0.020
3.359 0.019
3.51 0.30
3.58 0.29
3.69 0.32
3.64 0.28
3.62 0.32
1.86 0.\3
!.90 0.12
1.92 0.11
1.92 0.12
1.90 0.14
1.16 0.14
l.l8 0.15
1.12 0.12
1.04 0.13
0.93 0.14
Table II. Blood viscosity and its major determinants throughout preeclamptic pregnancy Gestation (wk)
32 REFERENCES
111
No. of subjects Blood viscosity (centipoise) Mean SD Hematocrit Mean SD Plasma fibrinogen (gm/L) Mean SD Plasma viscosity (centipoise) Mean SD Erythrocyte deformability index Mean
SD
34
36
38
40
20
30
30
30
10
11.56 2 04
10.89 2.31
11.35 2.02
11.79 2.55
12.41 2.48
0.383 0.024
0.369 0.026
0.357 0.028
0.363 0.024
0.361 0.023
3.37 0.36
3.91 0.38
3.72 0.34
3.89 0.39
3.87 0.37
2.19 0.16
2.17 0.15
2.15 0.18
2.08 0.19
2.10 0.19
0.98 0.19
0.93 0.17
0.99 0.17
0.91 0.20
0.85 0.15
cosity has been suggested as a contributory factor, 2 and the recent finding of elevated plasma viscosity in preeclampsia3 supports this suggestion. This crosssectional study investigates blood viscosity and its major determinants in maternal and umbilical cord blood in normal and preeclamptic pregnancy. One hundred and twenty patients with preeclampsia
J.uw . o) .-\n>
I
Obsrer.
l
I i_.IX'/
C\lwc~>l.
the adult population makes the likelihood of its presence in transfusion blood rare. However, evidence of a fetomaternal transfusion out of proportion to estimated fetal blood volume in a patient with a history of recent blood transfusion may indicate the need to evaluate the transfused blood for the presence of persistent fetal hemoglobin. REFERENCES I. The Selective Use of Rho l(D) Immune Globulin (RLI G), A.merican College of Obstetricians and Gynecologists Technical Bulletin No. 61, March, 1981. 2. Pritchard, J. A., and MacDonald, P. C., editors: Williams Obstetrics, ed. 16, New York, 1980, Appleton-CenturyCrofts, chap. H, p. 185.
Ultrasonic placental grading and fetal pulmonary maturity R. VVILLIANf QUINLAN, !v1.D. AMELIA C. CRUZ, M.D.
Department of Obstetrics and Gynecology, University of Florida. College of Medicine, Gainesville, Florida
appearance of the placenta have been correlated to its maturation and to fetal pulmonary maturity. Crannum and associates 1 and Hobbins 2 have described a grading system based upon placental sonographic characteristics. In one study, 1 no patient with a Grade III placenta was found to have an amniotic fluid lecithin/sphingomyelin (LIS) ratio of less than 2: I. The authors also noted that, in complicated pregnancies, this placental change could be seen as early as 33 weeks' gestation. They have proposed that. if this relationship of placental maturation and fetal pulmonary maturity were to hold true, it might be possible to circumvent the need to obtain amniotic Huid for determination of fetal pulmonary maturity in patients in whom the performance of amniocentesis might be dangerous or contraindicated. In order to further investigate the correlation between the grading of placental maturity and fetal pulmonary maturity, a prospective study was established at the University of Florida. Pregnancies that required evaluation of amniotic fluid for fetal lung maturation were also evaluated by ultrasound for placental changes. Patients with pregnancy complications of diabetes mellitus, hypertension, Rh sensitization, or previous cesarean section were included. The placenta was evaluated both by static and real-time ultrasound, and two independent observers graded the placenta according to the scheme of Grannum and associates prior to the perforCHANGES IN ULTRASONIC
Reprint requests: Dr. R. William Quinlan, Department of Obstetrics and Gynecology, University of Florida, College of Medicine, Box J-294, JHMHC, Gainesville, Florida 32610. 0002-9378/82/010110+02$00.20/0 © 1982 The C. V. Mosby Co.
Fig. 1. :\nterior placenta \'/ith Grade ! l! l hLtnge~. iucludin~ calcification, centrilobular sonolucencv, ,md 'eptatiun ro tht· basal plate.
mance of amniocentesis. A pulmonan prof tie. including LIS ratio and detection ofphosphatidylglyn:T•Jl. wa~ performed on the Huid obtained. :'\o patients underwent deli\ery unless the LIS ratio was greater than :! : l and phosphatidylglvcerol was present in the amnioti< Huid, unless deliYery was obstetrically indicated beuusc of maternal complications. Among the patients studiul to date. three ha\C demonstrated all the charaneri,tin of a Grade III placenta bv the cla,sificat i.. n o! Gra 1!lll!IIl and co-workers but, on repeated determinations. had ;m immature LIS ratio that indicated ~~~~ absence ol fetal pulmonary maturity. One of the paticnr- is reported on here, by \\ay of illmtration. The patient was a 22-year-old nullipar<>th black 1\0t!l
Communications in brief
Volume 142 Number I
Labor was induced and the patient was delivered of a female infant who weighed 2,260 gm and had Apgar scores of 9 and 8 at 1 and 5 minutes, respectively. The infant did not exhibit any signs of respiratory distress in the neonatal period. Gross examination of the placenta, which weighed 400 gm, revealed gritty calcifications and multiple small placental infarcts. During the postpartum period, the mother required medication to control persistent hypertension.
Ultrasonic grading of placental maturation has been advanced by Grannum and associates 1 as a potential method for determining fetal pulmonary maturity in those pregnancies in which amniocentesis would be difficult or hazardous to the patient or fetus. In evaluating high-risk pregnancies complicated by hypertension, Rh isoimmunization, or diabetes, we have found that this method is not infallible in predicting fetal pulmonary maturity. We have observed an instance of a Grade III placenta with all the characteristic findings of calcification, interruptions of the chorionic plate to the basal layer, and sonolucent fallout areas, in a pregnancy in which there was an immature LIS ratio over a 3-week period. For this reason, placental grading by ultrasound cannot be expected to predict fetal pulmonary maturity in all instances of complicated pregnancy. Further investigation in a prospective manner will be necessary in order to validate the use of placental sonographic appearance in predicting fetal pulmonary maturity in the medically complicated pregnancy. We will continue our study along these lines 10 predict the accuracy of this clinical test.
Table I. Blood viscosity and its major determinants throughout normal pregnancy
No. of subjects Blood viscosity (centipoise) Mean SD Hematocrit Mean
SD Plasma fibrinogen (gm/L) Mean
SD Plasma viscosity (centipoise) Mean
SD Erythrocyte deformability index Mean
SD
30
I. Grannum, P. A. T., Berkowitz, R. L., and Hobbins, J. C.: The LIS changes in the maturing placenta and their relation to fetal pulmonic maturity. AM. J. 0BSTET. GvNECOL 133:91.5, 1979. 2. Hobbins,]. C.: Management decisions in OB, in Sabbagha, R. E .. editor: Diagnostic Ultrasound Applied to Ob & Gyn, Hagerstown, 1980, Harper& Row, Publishers, pp. 135-136.
Preeclampsia-A hyperviscosity syndrome PETER C. BUCHAN, B.Sc., M.D., M .R.C.O.G.
Department of Obstetrics arul GynMcology, St. james's University Hospital, Leeds, Englarul PREECLAMPSIA IS ASSOCIATED with fetal intrauterine growth retardation resulting from reduced intervillous placental blood flow. 1 The limitation of intervillous flow is attributed to narrowing of the vessel lumina by atherosclerosis: however, blood hypenis-
Reprint requests: Peter C. Buchan, Department of Obstetrics and Gynaecology, St. James University Hospital, Leeds, England LS9 7TF. 0002-9378/82/010111 +02$00.20/0 © 1982 The C. V. Iv1osby Cu.
30
30
30
30
8.83 1.48
7.72 1.62
8.92 1.54
9.56 1.60
9.34 1.71
0.346 0.020
0.342 0.018
0.348 0.019
3.358 0.020
3.359 0.019
3.51 0.30
3.58 0.29
3.69 0.32
3.64 0.28
3.62 0.32
1.86 0.\3
!.90 0.12
1.92 0.11
1.92 0.12
1.90 0.14
1.16 0.14
l.l8 0.15
1.12 0.12
1.04 0.13
0.93 0.14
Table II. Blood viscosity and its major determinants throughout preeclamptic pregnancy Gestation (wk)
32 REFERENCES
111
No. of subjects Blood viscosity (centipoise) Mean SD Hematocrit Mean SD Plasma fibrinogen (gm/L) Mean SD Plasma viscosity (centipoise) Mean SD Erythrocyte deformability index Mean
SD
34
36
38
40
20
30
30
30
10
11.56 2 04
10.89 2.31
11.35 2.02
11.79 2.55
12.41 2.48
0.383 0.024
0.369 0.026
0.357 0.028
0.363 0.024
0.361 0.023
3.37 0.36
3.91 0.38
3.72 0.34
3.89 0.39
3.87 0.37
2.19 0.16
2.17 0.15
2.15 0.18
2.08 0.19
2.10 0.19
0.98 0.19
0.93 0.17
0.99 0.17
0.91 0.20
0.85 0.15
cosity has been suggested as a contributory factor, 2 and the recent finding of elevated plasma viscosity in preeclampsia3 supports this suggestion. This crosssectional study investigates blood viscosity and its major determinants in maternal and umbilical cord blood in normal and preeclamptic pregnancy. One hundred and twenty patients with preeclampsia