Mental illness in homeless women: an epidemiological study in Munich, Germany

This longitudinal observational study evaluates the stage at which coronary flow can be visualized by color-coded and pulsed wave Doppler sonography in fetuses with normal cardiac anatomy. Fetal biometry, echocardiography and Doppler examination of the umbilical and middle cerebral arteries, ductus venosus, inferior vena cava and umbilical vein were performed in 109 cases. Fetuses were divided into five groups based on the Doppler examination of the umbilical artery, birth weight and the ability to visualize coronary blood flow. Coronary blood flow was identified in six of 55 fetuses with normal growth who had normal Doppler studies and perinatal outcome. In these, visualization of coronary blood flow was possible after 31 weeks' gestation at a median gestational age of 37 weeks. Coronary blood flow was also visualized in ten of 54 fetuses with severe intrauterine growth retardation and highly pathological flow velocity waveforms in all vessels soon after a significant increase of venous indices in the inferior vena cava and ductus venosus. In these cases, coronary blood flow was identified at a significantly earlier gestational age (median 27 weeks). These fetuses had a poor perinatal outcome (average birth weight less than 3rd centile, mortality rate 50%, significantly lower umbilical artery blood pH and Apgar scores after 1 and 5 min). Intrauterine fetal death occurred in five fetuses after a median of 3.5 days following visualization of coronary blood flow. Median coronary peak blood flow velocities in the right coronary artery were higher in intrauterine growth-retarded than appropriate-for-gestational-age fetuses.     

Doppler flow velocity waveforms of the umbilical arteries correlate with intravillous blood volume

OBJECTIVE: My purpose was to measure the volume of the fetoplacental vessel tree and to relate findings to Doppler flow patterns of the umbilical arteries. STUDY DESIGN: One hundred sixty placentas were examined by means of standardized random block placental histomorphometry after delivery and the results were compared with antenatal Doppler findings. RESULTS: There was a high correlation (r = -0.703) between the intravillous blood volume obtained from measurements of intermediate and terminal villi and the Doppler flow velocity waveforms detected within the last week before delivery. Moreover, the reduced size of a vessel tree less than 85 mL is highly predictive of perinatal complications, such as fetal growth restriction, low umbilical artery pH values after birth, reduced Apgar scores, and cesarean section for fetal distress. CONCLUSION: These data suggest that reduced end-diastolic flow velocities in the umbilical arteries are associated with elevated fetoplacental impedance owing to reduced vascularization of intermediate and terminal villi.     

Mutations and deletions within the hepatitis B virus core antigen and locations of B cell recognition sites

One or more infants of a multifetal pregnancy occasionally require delivery selectively because of in utero risk of fetal death in circumstances in which the sibling fetus appears well. At 26 weeks 5 days of gestation a small fundally placed twin in a dichorionic gestation had an estimated fetal weight of 650 g with decreased amniotic fluid and ominous Doppler velocity findings in his umbilical artery. A normally grown presenting sibling had reassuring fetal surveillance data. Over a 2-week interval the growth-restricted twin showed no growth, and his status deteriorated. He was selectively delivered by hysterotomy. Selective delivery may offer parents of multifetal gestations an additional option when 1 or more of their fetuses are at high risk for in utero death.     

The response regulator-like protein Pos9/Skn7 of Saccharomyces cerevisiae is involved in oxidative stress resistance

To assess the standard curves of pulsatility index (PI) in different segments of middle cerebral artery (MCA): initial segment (MI) and subcortical segment (M2); to determine the variation of the flow velocity waveforms (FVW) of the M1 and M2 segments of MCA in presence of fetal distress and to establish the possible correlation between the two segments of MCA. 50 normal pregnancies from 25 weeks of gestation to term and 20 pregnancy with alteration of fetal growth rate were investigated with serial records of the FVW of the M1 and M2 segments of the MCA and of the umbilical artery (UA) with a colour Doppler system. Severe fetal distress was associated to cerebral-placental ratio below 1 (C/P < 1). The perinatal outcome was established on the basis: 1) abnormal intrapartum CTG, 2) emergency cesarean section, 3) Apgar score at 1st and 5th minute after birth and 4) birth eight centiles. In normal pregnancy P1 of M2 was always higher than that of M1: therefore M2/M2 resulted below 1, with a maximum peak near 32 weeks of gestation. In presence of moderate fetal distress only P1 of M2 was reduced (M1/M2 > 1). It exists a significant difference of PI in M1 and M2 segments of fetal MCA during gestation: thus MCA so it is important to identify the tract of fetal MCA when recording its FVW. Moreover we suppose that an initial "cerebral sparing" effect exists in order to protect the cortex by the initial hypoxic injury: this is shown by a M1/M2 > 1. The progression of fetal distress results in a greater haemodynamic modification, the so called "brain sparing" which is usually present when C/P < 1.     

The head-to-abdomen circumference ratio: a reappraisal

Our objective was to assess the clinical significance of the sonographically derived head-to-abdomen circumference ratio in small-for-gestational-age (SGA) fetuses. The head-to-abdomen ratio was determined in 134 singleton SGA fetuses without ultrasound evidence of malformations at 26-40 weeks' gestation. Data were collected regarding antenatal surveillance, umbilical artery Doppler velocimetry and neonatal outcome. In SGA fetuses, the head-to-abdomen ratio, adjusted for gestational age, had a normal frequency distribution, positively skewed with regard to fetuses with normal birth weight. An elevated head-to-abdomen ratio was found in 56 SGA fetuses (42%), and was associated with increased perinatal mortality (odds ratio 3.27; 95% confidence internal 1.04-9.34), lower birth weight (1533 +/- 635 g vs. 2022 +/- 655 g, p < 0.0001) and lower gestational age at delivery (34 +/- 3.6 weeks vs. 36.3 +/- 3.6 weeks, p < 0.005). However, logistic regression revealed that the most powerful antenatal determinants of pregnancy outcome were Doppler velocimetry of the umbilical artery, followed by biophysical profile, while no independent correlation was found with the head-to-abdomen ratio. The existence of two distinct categories of SGA fetuses, 'symmetric' and 'asymmetric', remains uncertain. An elevated head-to-abdomen ratio is an adverse risk factor for pregnancy outcome. However, this parameter has no clearcut clinical value when umbilical artery Doppler velocimetry and biophysical antenatal testing are available.     

Effect of dehydroepiandrosterone sulfate on fetal middle cerebral artery flow velocity waveforms in term pregnancy

OBJECTIVE: To investigate whether bolus injection of dehydroepiandrosterone sulfate (DHAS) is associated with changes in fetal middle cerebral artery flow velocity waveforms in term pregnancy. METHODS: Ten normal full-term pregnant women received the administration of a 200-mg intravenous dose of DHAS in 20 ml of 5% dextrose. Ten normal full term pregnant women received 20 ml 5% dextrose as controls. Color Doppler flow imaging and pulsed Doppler ultrasonographic assessments were made on fetuses in each group before and 10 min, 30 min, 60 min, 90 min. and 120 min after DHAS or dextrose administration. The pulsatility index (PI) values for the middle cerebral artery, and umbilical artery, and fetal heart rate were recorded. RESULTS: In the DHAS group, middle cerebral artery PI decreased from baseline by 24% (p<.05) after 10 min, and the mean reduction was 22% (p<.05) after 30 min. The PI returned to the baseline value 60 min later. In the control group, there was no change in middle cerebral artery PI. No change was found in umbilical artery PI or fetal heart rate in the control or DHAS group. CONCLUSION: DHAS induces a significant decrease in the fetal middle cerebral artery PI, which suggests a possible decrease in fetal cerebral vascular impedance in term pregnancy.     

Hydrocephalus in one twin after massive reverse flow in the umbilical artery in the 2nd trimester

The case of a twin pregnancy with severe diastolic reverse flow in the umbilical artery of one of the twins at 23 weeks' gestation is reported. After delivery at 29 weeks' gestation, a congenital internal hydrocephalus was diagnosed in this twin. The most probable aetiology is an intrauterine periventricular haemorrhage. The severe diastolic reverse flow in the umbilical artery seems to represent a highly pathological flow pattern of prefinal degree, possibly leading to cerebral defects. The pathophysiology of the Doppler findings and the pathogenesis of the internal hydrocephalus are discussed.     

Experimentally contaminated reabsorbable meshes: their evolution in abdominal wall defects

The effect of maternal hyperglycemia on fetal regional circulation in appropriate for gestational age and small for gestational age fetuses was evaluated. Color Doppler flow imaging and pulsed Doppler ultrasonographic assessments were made on 15 appropriate for gestational age and 19 small for gestational age fetuses, ranging from 33 to 40 weeks' gestation before, 60 minutes, and 120 minutes after a maternal 75 g glucose load. The pulsatility index (PI) was calculated for middle cerebral artery, descending aorta, splenic artery, renal artery, femoral artery, and umbilical artery. Simultaneously, maternal plasma glucose concentration was measured. Baseline PI value (1.50 +/- 0.31) for middle cerebral artery in small for gestational age fetuses was significantly lower than that (1.89 +/- 0.37) in appropriate for gestational age fetuses (p < 0.05); however, there were no significant differences in baseline PI values for other arteries in both groups. In appropriate for gestational age fetuses, the mean PI decreased from 1.89 +/- 0.37 to 1.47 +/- 0.33 at 60 minutes, and to 1.55 +/- 0.32 at 120 minutes (p < 0.05), but no changes were found in the other arteries. In small for gestational age fetuses, there was no significant change in PI value for each artery before and after maternal glucose load. Maternal hyperglycemia induces a significant decrease in cerebrovascular resistance in appropriate for gestational age fetuses but not in small for gestational age fetuses. These results provide a foundation for evaluating the effect of maternal hyperglycemia on fetal regional circulation.     

Cardiac flow after fetal blood sampling in normally grown and growth-retarded fetuses

The objective of this study was to evaluate the effect of fetal blood sampling on cardiac flow velocity waveforms. Flow velocity waveforms were measured from the ascending aorta and pulmonary artery immediately before and after fetal blood sampling in 29 normally grown and 12 growth-retarded fetuses. The latter group was characterized by abnormal Doppler indices in the umbilical artery and middle cerebral artery suggestive of uteroplacental insufficiency as the causative factor of the impaired growth. The flow velocity parameters studied were the peak velocity, the time to peak velocity, and the left and right cardiac output and their ratio. In normally grown fetuses, the peak velocity and right and left cardiac output values increased significantly after fetal blood sampling, while no significant changes were observed in the other indices considered. The gestational age at the time of the procedure was positively related to the amplitude of these changes. In growth-retarded fetuses, fetal blood sampling did not induce any significant increase in cardiac output or peak velocities, while in more than 50 per cent of the fetuses these Doppler indices decreased. The amplitude of the decrease was significantly related to the severity of acidosis in the umbilical vein. In conclusion, the cardiac haemodynamic response to fetal blood sampling differs between normally grown and growth-retarded fetuses. This difference may explain the higher rate of complications occurring in the latter group of fetuses after blood sampling.     

Reversed end-diastolic umbilical flow in a first-trimester fetus with congenital heart disease

Reversed end-diastolic umbilical artery velocities and a reduced chorionic sac were first seen at 10 weeks in a pregnancy subsequently showing a normal male karyotype on chorionic villi. Four weeks later Doppler studies demonstrated normal umbilical artery waveforms. At 20 weeks, ultrasound examination of the fetus revealed a mild pericardic effusion, hypoplastic righ heart with hypertrophic myocardium and a single umbilical artery, suggesting pulmonary atresia. After neonatal death, pathological studies confirmed pulmonary atresia. This case suggests that reversed end-diastolic umbilical flow in the first trimester may identify a subgroup of fetuses with a lethal abnormality (heart defect, severe intra-uterine retardation, aneuploidy or others).     

Patch testing in children

Indomethacin is a very effective tocolytic agent. However, concern about its possible constrictive effect on fetal ductus arteriosus has limited the use of this medication in pregnancy. A 29-year-old woman was treated with indomethacin at 27 weeks of gestation for preterm labor and polyhydramnios. She received a dose of 75 mg/day for 5 weeks. At 35 weeks of gestation, she had a cesarean delivery due to fetal distress, and a hydropic baby was delivered. The infant died shortly after. Nonimmune hydrops fetalis and closed ductus arteriosus were the only pathological findings at autopsy. In utero, irreversible, complete closure of the ductus arteriosus is very rare. In the case presented, prolonged use of indomethacin during pregnancy was associated with complete closure of the ductus arteriosus that developed most probably after discontinuation of therapy. This case emphasizes the need for frequent fetal echocardiography examinations during as well as after maternal indomethacin treatment.     

Changes in appearance of amniotic fluid during pregnancy - the macroscore

During the first two trimesters of pregnancy the amniotic fluid is clear and yellow; during the third trimester the amniotic fluid becomes colourless; then, approximately from the 33rd-34rd week on, cloudiness and flocculation occur, at first very slowly, after the 36th-37th week steadily faster (Tab. I). At term, the amniotic fluid is moderately cloudy and contains a moderate number of flakes of vernix. The appearance of the amniotic fluid depending on the degree of cloudiness and on the number of flakes, has been expressed by means of a score system, the socalled macroscore (Tab. II). Relationships were observed: a) between the disappearance of the yellow colour (bilirubin) and the initial occurrence of cloudiness and flocculation; b) between the duration of pregnancy and the macroscore; from the 32nd-36th week of pregnancy the mean macroscore increases until the second half of the 40th week; then in the 41 st week there is a drop in the mean macroscore, after which a new increase occurs (Fig. 1,2 and 3). c) between the total gestation period at birth and the progression of the macroscore (Fig. 5); when birth takes place earlier (later), the macroscore will increase earlier (later). d) between the total duration of gestation at birth and the macroscore at the end of pregnancy; with an earlier (later) birth, the macroscore is lower (higher) (Fig. 5 and 6). With the macroscore it is possible to determine the duration of pregnancy (b) and the time before birth even more accurately (c). The fairly large standard deviation of the macroscore per pregnancy week (Fig. 1) also in case of a given duration of gestation at birth (Fig. 7) points to a fairly large interindividual variation in the appearance of the amniotic fluid at a certain duration of pregnancy. The macroscore is determined by elements originating from the fetal skin; the cloudiness and flocculation are caused by release of vernix and the flaking off of cells from the stratum corneum. Hence the macroscore reflects changes in the function of the fetal skin and is an indicator of the functional maturation of the fetal skin. The considerable variation of the macroscore at a given duration of pregnancy indicates a great variation of fetal maturation. The fetus that is maturing faster, will be delivered earlier; the fetus that is maturing slower, later (c). This points to a correlation between the degree of fetal maturation and the start of labour. The higher macroscore during the last days before birth in pregnancies of longer duration (d) (Fig. 5 and 6) may be explained by a less sensitive uterus, requiring a greater maturity of the fetus for delivery to start. The drop of the mean macroscore in the 41 st week of pregnancy is due to a sudden increase of lower scores in this week (Fig. 4). A lower score at a given stage of pregnancy means a later birth (Tab. VI and VII). Thus in the 41 st week of pregnancy a considerable group of pregnant women appears, that has a total duration of gestation that is, on the average, two weeks longer than normally...     

Vaginal birth after cesarean delivery: an admission scoring system

OBJECTIVE: To develop a scoring system to predict the likelihood of vaginal birth in patients undergoing a trial of labor after previous cesarean delivery using factors known at the time of hospital admission. METHODS: Trial of labor was attempted in 5022 patients who were assigned randomly to score derivation and score testing groups. Multivariate logistic regression modeling was used in the score derivation group to develop a predictive scoring system for vaginal birth. The scoring system was then applied to the testing group to evaluate its predictive ability. RESULTS: Five variables significantly affected the mode of birth and were incorporated into a weighted scoring system. Rates of successful vaginal birth after cesarean ranged from 49% in patients scoring 0-2 to 95% in patients scoring 8-10. Increasing score was associated linearly with increasing probability of vaginal birth after cesarean. CONCLUSION: Increasing scores correlate with increasing probability of vaginal birth after cesarean. The admission vaginal birth after cesarean scoring system may be useful in counseling patients regarding the option of vaginal birth or repeat cesarean delivery. This information could be particularly valuable for the patient who opts for trial of labor but has second thoughts about her mode of birth when labor begins.     

Mutations in hepatitis B DNA polymerase associated with resistance to lamivudine do not confer resistance to adefovir in vitro

A total of 96 women undergoing in-vitro fertilization (IVF) treatment were examined by transvaginal ultrasonography with colour and pulsed Doppler ultrasound on the 22nd day of the menstrual cycle preceding IVF. We assessed endometrial thickness, endometrial morphology, myometrial echogenicity, subendometrial vascularization, the uterine artery pulsatility index, protodiastolic notch and end diastolic blood flow in order to define a uterine score which could be correlated with the pregnancy rate. The overall pregnancy rate was 30.2%, and there was no difference between the pregnant and non-pregnant groups with regard to any of the ultrasonographic and Doppler parameters when examined separately. However, the uterine score was significantly higher in the pregnant group (15.9 +/- 2.81 versus 12.7 +/- 5.3, P = 0.002; t-test). No pregnancy occurred if the score was between 0 and 10. With a score of 11-15 there was a 34.7% chance of pregnancy, and scores >16 had a 42% chance of pregnancy. In conclusion, individual ultrasonographic and Doppler parameters are not of sufficient accuracy to predict uterine receptivity. The uterine score calculated prior to IVF cycles appears to be a useful predictor of implantation.     

Impaired postnatal cerebral perfusion after prenatal centralization-- increased risk of neonatal brain injury?

Within the last years Doppler sonographic studies in high risk pregnancies had been included into obstetrical management strategies. Especially the high fetal risk in cases with severe intrauterine perfusion disturbances with signs of hemodynamic centralization--the brain sparing effect--had been established. In 11 premature newborns with prenatal sonographic recorded vasodilatation of cerebral vessels as a sign of hemodynamic centralization flow velocity waveforms of the anterior cerebral artery as well as left cardiac functional parameters (LVET, PEP) were measured at the 1st, 2nd, 3rd, 5th and 6th day of life. For the evaluation of the peripheral circulation the perfusion of the superior mesenteric artery was recorded by Doppler ultrasound. Additionally, the blood pressure, heart rate, pH and acid base status was considered. We used 25 premature newborns of corresponding gestational age and normal prenatal Doppler sonographic findings as a control group. In the group with prenatal brain sparing effect we could demonstrate a remarkable increase of the pulsatility index as a result of extreme diminished diastolic blood flow velocity. 5 newborns showed signs of reverse diastolic flow. The difference to the control group was highly significant. Perfusion measurements in the superior mesenteric artery demonstrated corresponding results at the first day of life with significant increased PI and diminished diastolic flow velocities. Our results demonstrate the great importance of prenatal diagnosis for the understanding of postnatal disturbances. The birth is not the endpoint of fetal hemodynamic centralization and the compensational mechanism is still continuing. Despite a well adapted cardiac function, normal hemodynamic situation and balanced metabolic findings remarkable changes of the impedance of the cerebral vessels are evident. Especially for the very immature newborns this may lead to the risk of leasions of the germinal matrix with following hemorrhage or ischaemic injury.     

Repeated cesarean section

Pregnancies after repeated cesarean sections are often considered to carry high maternal and fetal risks. The pregnancy course, intraoperative and postoperative complications and conditions of newborns were compared between 53 patients who had two or more previous cesarean sections and 58 women sectioned for the second time. No statistical difference was found between the two groups except for intraoperative complications.     

Advances in fetal echocardiography

Fetal echocardiography is the primary modality for defining and evaluating fetal cardiac status and requires detailed analysis of the cardiac anatomy from numerous views and Doppler interrogation of the intracardiac structures, great vessels, and umbilical artery. Referrals for fetal echocardiography are determined by fetal, maternal, or familial risk factors; however, approximately 50% of neonates diagnosed with a congenital cardiac defect have no risk factor, and most have undergone an obstetrical ultrasound during the pregnancy that did not detect a cardiac defect. Advances in transducer technology have resulted in the development of small high-frequency transvaginal probes that allow fetal cardiac interrogation earlier during gestation. On the horizon is 3-dimensional fetal echocardiography, which provides rapid image acquisition and tremendous computer image reconstruction ability. At present, the computer image data analysis process is lengthy, and several technical limitations must be overcome before 3-dimensional fetal echocardiography becomes the primary modality of fetal cardiac imaging. New Doppler Tissue Imaging using color Doppler energy mapping allows more precise anatomic definition of the fetal endocardium, facilitating diagnosis of small ventricular septal defects. These new advances, along with improved image resolution, provide obstetricians and pediatric cardiologists with more tools and techniques for earlier and more precise detection of fetuses with cardiac defects.     

Editorial: Opportunistic infections due to Aspergillus

Changes in plasma thyroxine (T4) concentrations were followed in 27 fetal sheep after surgical implantation of catheters. Fourteen days were required before stable concentrations of T4 were achieved, whether surgery was performed between 90 and 96 days or 109 and 120 days gestation. Twenty-three fetuses were followed to birth, and during the last four days the T4 concentrations showed no change in 11 fetuses and a significant decrease in the other 12. Birth occurred between 142 and 157 days gestation in both groups. There was a significant rise in T4 concentration during labour in all 23 fetuses. There were large differences among the plasma T4 concentrations of individual ewes which were not related to ambient temperature.     

Experimental and clinical study on the blood supply of the subdermal vascular network island flap]

Vascular resistances of various fetal areas are assessed by Doppler ultrasound. The PI, RI and S/D indices are measured on the cerebral, renal, aortic and umbilical Doppler spectrum. Ratios of these indices based on the comparison of the cerebral (Rc) and the umbilical (Rp) resistances, or carotid (Rcc) and umbilical resistances, or cerebral (Rc) and aortic (Rao) resistances (Rc/Rp or Rp/Rcc, or Rc/Rao), measure the flow redistribution between the placenta and brain. The umbilical resistance indices, when greater than the upper limit of the normal range (> 2sd) are frequently associated with IUGR. (Sensitivity about 65 to 70%). Absent end diastolic flow is most of the time associated with severe IUGR and hypoxia and poor fetal outcome. A fairly good correlation was found between the existence of significantly decreased (< .2.sd) cerebral resistance and the development of post asphyxial encephalopathy in the neonate (Specificity 75% Sensitivity 87%). The earliest detectors of IUGR and hypoxia are the cerebral-umbilical cerebral-carotid, or cerebral-aortic ratios (Sensitivity 85% specificity 90%). When used as predictor of poor perinatal outcome in growth retarded fetuses, the cerebral umbilical ratio shows a sensitivity of 90% compared with 78% of the middle cerebral artery, and 83% for the umbilical artery indices. Changes of this ratio are well correlated with the fetal pO2 changes. The renal flow response to hypoxia depends on the degree of hypoxia. Opposite responses were found in case of moderate, and severe IUGR or hypoxia. Thus, it is too early to conclude if the renal indices are reliable parameters for the evaluation of fetal hypoxia. The sensitivity in predicting IUGR was for the aortic PI: 41% and for the aortic BFC (Blood flow classes): 57%. In predicting delivery for fetal distress, the corresponding values were 76 and 87%, respectively. Because the resistance indices are heart rate-dependent, it is dangerous to draw any conclusion from one single value of any of these parameters. Only several successive measurement of the Doppler indices or of their ratio, may lead to a reliable evaluation of fetal hemodynamics. In the case of significant IUGR with abnormal Doppler indices it is recommended to repeat the Doppler measurements daily both at the cerebral and umbilical or aortic level in order to follow up the fetal flow redistribution which is highly correlated with the fetal pO2 changes.