HPLC detection of fetal blood in meconium: improved sensitivity compared with qualitative methods

We describe an HPLC-based method for the detection and quantification of fetal hemoglobin in stools of newborns. The new procedure is an alternative to the classic qualitative test for adult hemoglobin in meconium based on the differential stability of hemoglobin species in dilute base (Apt test). The HPLC method, based on a commercial device for hemoglobin characterization (Bio-Rad Variant), readily separates fetal and adult hemoglobin from non-hemoglobin components of meconium. To validate the method, blood and meconium were mixed in various proportions and then prepared for analysis with extraction in saline. The HPLC method accurately identified hemoglobin species even when the blood constituted only 5 mL per 100 g of the meconium specimen, and nearly quantitative recovery of hemoglobin was obtained at a blood content of 20 mL per 100 g of the meconium. Analysis time was 6.5 min, and preparation of sample was simple. HPLC detection of fetal blood in stools or other specimens markedly improves detection/characterization of blood in meconium.     

Association of clinical intra-amniotic infection and meconium

The objective of this study was to determine the rate of intra-amniotic infection in patients with meconium-stained amniotic fluid compared to controls. With a retrospective case-controlled study design, we compared 100 pregnant women with meconium to 100 pregnant women without meconium for the development of intra-amniotic infection. Patients delivered between September 1 and December 31, 1990. Exclusion criteria were active infection prior to labor or antibiotic use within the 7 days prior to delivery. We diagnosed clinical intra-amniotic infection in patients with ruptured membranes by a maternal temperature 100.4 degrees F or higher and any two of the following: maternal or fetal tachycardia, uterine tenderness, white blood cell count 10,500 mm3 or more, or foul-smelling amniotic fluid. Demographic variables, labor characteristics, maternal infectious morbidity, and neonatal outcome were analyzed using the Wilcoxin rank test, chi-square test, or Fisher's exact test as appropriate. The rate of clinical intra-amniotic infection was significantly higher in women with meconium-stained amniotic fluid (8%) compared with women with no meconium (2%) (p = 0.05).     

Spontaneous rupture of right iliac arterial aneurysm into ureter

Severe hypoxia unresponsive to maximum ventilatory support occurs both in idiopathic respiratory distress syndrome and meconium aspiration. We recently encountered a 980 g female infant with respiratory distress syndrome and 3 300 g female infant with meconium aspiration and persistant fetal circulation whose clinical course necessitated the use of tolazoline and dopamine to reduce pulmonary and to stabilize systemic pressures. The infant with respiratory distress syndrome responded with a PaO2 increase of 2.7 kPa while the infant with persistant fetal circulation and meconium aspiration showed a 51.6 kPa rise. Combined pharmacologic therapy may have a role in improving oxygenation status in severely hypoxemic infants receiving maximum support.     

Justification of caesarean section for fetal distress

A study was done from May 1995 to February 1996 to evaluate the justification of caesareans for fetal distress by examining the circumstances leading to operative delivery for compromised fetus. Of the 1096 caesareans, 179 (16.33%) were for fetal distress. One hundred and seven (59.78%) were nulliparas and 127 (71%) came with the clinical features of fetal hypoxia. In 142 (79%) parturients at the time of c-section, cervical dilatation varied from 0-3 cm and in 144 (80%) the presenting part remained unengaged. The method most commonly employed to diagnose fetal distress was the external cardiotocography, used in 141 (79%) patients either alone or in combination with other options. Predictivity value of the parameters used to identify the fetuses at jeopardy was found to be more sensitive when used in combination. Neonatal outcome related poorly with the preoperative diagnosis if only one parameter was used. Poorest neonatal outcome was observed in the presence of thick particulate meconium. Great care should be exercised by the obstetricians while making a decision for caesarean for fetal distress so as to avoid unnecessary procedures and neonatal complications.     

Developmental pattern of 3-oxo-delta 4 bile acids in neonatal bile acid metabolism

AIMS: To investigate whether a fetal pathway of bile acid synthesis persists in neonates and infants. METHODS: 3-oxo-delta 4 bile acids were determined qualitatively and quantitatively in the urine, meconium, and faeces of healthy neonates and infants, using gas chromatography-mass spectrometry. RESULTS: The mean percentage of 3-oxo-delta 4 bile acids in total bile acids in urine at birth was significantly higher than that at 3 or 7 days, and at 1 or 3 months of age. The concentration of this component in meconium was significantly higher than that in faeces at 7 days and at 1 or 3 months of age. CONCLUSIONS: The presence of large amounts of urinary 3-oxo-delta 4 bile acids may indicate immaturity in the activity of hepatic 3-oxo-delta 4-steroid 5 beta-reductase in the first week of postnatal life. Large amounts of this component in meconium may be due to the ingestion of amniotic fluid by the fetus during pregnancy.     

Persistent fetal circulation: an evolving clinical and radiographic concept of pulmonary hypertension of the newborn

The roentgenographic presentations of 11 newborn infants with hypoxemia secondary to pulmonary vasospasm and subsequent right-to-left shunting of blood through the foramen ovale and/or ductus arteriosus (persistent fetal circulation) are described (P. F. C. Syndrome). One infant had radiographically normal lungs, while ten had pulmonary parenchymal abnormalities including hyaline membrane disease [4], meconium aspiration syndrome [4], or an ill defined pattern of retained lung fluid [2]. The roentgenographic appearance of the lungs, however, was discordant with the severe hypoxemia observed in most. Heart size was variable but some degree of cardiomegaly was commonly present. Tolazoline, a potent vasodilator, was useful diagnostically and may have resulted in increased survival. An expanded clinical and roentgeonographic concept of the PFC syndrome is suggested.     

Cocaine and metabolites in amniotic fluid may prolong fetal drug exposure

OBJECTIVE: Cocaine and metabolites can be found in the amniotic fluid after maternal use, presumably as a result of fetal urination. The fetus may be repeatedly exposed to the effects of these drugs through contact with amniotic fluid that contains these substances. The purpose of this study was to determine whether the naive fetal lamb generates detectable fetal blood levels of cocaine and metabolites when cocaine is placed directly into the amniotic fluid and, if so, whether fetal swallowing accounts for these findings. STUDY DESIGN: Six pregnant ewes with singleton fetuses of 120 to 125 days' gestation were chronically catheterized for daily sampling of cocaine and metabolite levels in maternal venous plasma, fetal venous plasma, and amniotic fluid over a 7-day period. Esophageal ligation was performed in three additional animals similarly instrumented to evaluate the role of fetal swallowing in the distribution of amniotic fluid cocaine and its metabolites. In each case, at the time of surgery, an Alzet osmotic pump delivering cocaine at 0.5 mg/kg estimated fetal weight per hour into the amniotic fluid was secured to the fetal back. Cocaine and metabolites (benzoylecgonine, ecgonine methyl ester, and norcocaine) were measured daily in material and fetal plasma, amniotic fluid, and meconium by solid-phase extraction and derivatization and quantified by high-performance gas chromatographic techniques. RESULTS: The concentrations of ecgonine methyl ester were highest in the amniotic fluid followed by cocaine and benzoylecgonine. In the normal and esophagus-ligated groups, cocaine, benzoylecgonine, and norcocaine were found in fetal plasma in concentrations of approximately 3% that of amniotic fluid. Ecgonine methyl ester was not detected in fetal plasma from either group. Meconium samples from sheep with and without esophageal ligation demonstrated high levels of norcocaine. CONCLUSION: We conclude that cocaine and metabolites in amniotic fluid enter the fetal circulation to produce detectable plasma levels through routes other than swallowing. Moreover, the results of meconium analyses in the two groups of fetuses suggest that fetal swallowing is not the primary mechanism by which cocaine and metabolites enter the intestine.     

Prolonged pregnancy. Review of the literature

There have been various estimations of the frequency of postdate pregnancies. On the average, 10% of all pregnancies exceed 42 weeks amenorrhoea with a range from 4 to 14% according to the authors. Rates vary with use of ultrasound examinations early, avoiding false dating and induced labour. A pregnancy becomes a pregnancy at risk at the end of the 41st week of amenorrhoea. Fetal maturity may be affected by a disease process or due to individual or ethnic variations. The potential danger of prolonged pregnancy is inhalation of meconium prepartum. Expulsion of meconium is both a frequent consequence of fetal distress and the result of increased intestinal reactivity. There does not appear to be agreement on the degree of risk of sudden death at the end of pregnancy, although the risk does appear to exist. Surveillance should include recording fetal heart rate under basal conditions and an assessment of the amniotic fluid volume with ultrasounds. The Doppler technique is currently under study. When the status of the cervix is favourable, labour may be induced by rupturing the membranes of with a perfusion of Syntocinon. When the status of the cervix is unfavourable, prostaglandin E2 is applied intravaginally or intracervically with a gel. Therapeutic trial published to date do not demonstrate any advantage over cesarean section or fetal morbidity. The safety of the procedure has not been proven. Randomized trials comparing systematic induction of labour with a wait-and-see attitude have not given a definitive answer. Only two trial have shown a significant advantage of systematic induction of labour. The others have shown that the rate of cesarean section and neonatal morbidity are comparable in the two groups.     

Developmental pattern of bile acid metabolism as revealed by bile acid analysis of meconium

The developmental metabolism of bile acids can be partly studied by the analysis of bile acid patterns in meconium. Employing modern analytical techniques, it has been found that besides the main bile acids of humans (cholic, chenodexoycholic, deoxycholic, and lithocholic acids) several "atypical" bile acids occur in meconium. It is unlikely that these "atypical+ bile acids are derived from materno--fetal transfer, and they therefore probably reflect a special fetal bile acid metabolism. Hydroxylations at positions 1 and 6 of the steroid skeleton are regularly encountered. These hydroxylations, as well as the occurrence of 3 beta-hydroxy-delta 5 compounds and of bile acids of the 5 alpha series, suggest that fetal bile acid synthesis differs markedly from that of the adult. These observations are of interest in relation to the origin of unusual bile acids found in the cholestatic condition of the adult. It appears that a resurgence of the fetal biosynthetic patterns takes place under the conditions of cholestatic liver disease.     

Meconium ileus and intestinal atresia in fetuses and neonates

A collaborative study was performed to determine the different types and mechanisms of intestinal abnormalities during gestation. Cases had to fulfill one or more of the following three criteria: (1) meconium ileus, (2) intestinal stenosis or atresia, and (3) meconium peritonitis. Esophageal atresia, anorectal atresia, and abdominal wall defects were excluded. One hundred two cases were reviewed from the autopsies of 42 induced abortions, 22 stillborns, and the surgical findings in 38 neonates. Meconium ileus was detected mainly during the second trimester (28/38), and was associated with cystic fibrosis (15), fetal blood deglutition (4), infection (6), or multiple-abnormalities (10), in which three chromosomal aberrations were found. Intestinal stenosis or atresia was more commonly detected during the third trimester of gestation (46/56). Sixteen of the 30 duodenal malformations were associated with trisomy 21, whereas in the 26 small intestinal atresias, signs of distress or ischemia were most frequently detected. Only 8 of 25 meconium peritonitis cases were isolated. A total of 20 cystic fibrosis cases could be proved. In this series, functional abnormalities were observed predominantly in the second trimester and associated mainly with cystic fibrosis or amniotic fluid abnormalities. Anatomic lesions were commonly detected later on and associated with ischemic conditions, chromosomal aberrations, and even cystic fibrosis.     

Amnioinfusion-induced malpresentation

Amnioinfusion is a valuable and common intrapartum procedure for the relief of cord compression and to dilute thick meconium. Like most procedures, it is not without risk and we report a case of malpresentation following amnioinfusion. Intrapartum fetal demise occurred after malpresentation during amnioinfusion resulting in a change of fetal presentation from vertex to unrecognized shoulder presentation. Further study is needed regarding changes in volume of amniotic fluid and saline as well as intrauterine manipulation and the effect on fetal presentation. Careful attention must be paid to infused volumes during amnioinfusion.     

Current status in the diagnosis and therapy of meconium ileus

Meconium ileus is in most cases difficult to diagnose preoperatively; however, aganglionosis should be excluded in every case (rectal double-suction biopsy, manometry). In cases of uncomplicated meconium ileus (no perforation, no further intestinal obstructions) lysis of the meconium by a Gastrografin enema is tried first. In case of no relief, an intraoperative puncture of the bowel and Gastrografin instillation is performed. If there is no relief a small bowel resection is performed and a Bishop-Koop anastomosis or a chimney anastomosis established. A distinction must be made between meconium ileus, meconium disease, meconium plug syndrome, and curd obstruction. Results show a survival rate of 80%.     

A case of recurrent esophageal cavernous hemangioma increasing rapidly after surgery

AIM: This study was designed to stress the importance of early diagnosis of fetomaternal hemorrhage (FMH) in attempt to prevent the subsequent adverse outcome on the fetus and the newborn. PATIENTS AND METHODS: Nine newborns were admitted because of neonatal anemia to our neonatal unit from October 1989 through September 1995. The diagnosis of FMH was made by the sigma diagnostic fetal hemoglobin that is the Kleihauer test in our hematologic laboratory. Other causes of neonatal anemia have been ruled out. RESULTS: Seven out of the nine cases have expressed early signs of fetal distress in term of abnormal fetal monitoring and/or thick meconium associated with decreased fetal movements. At birth, a wide clinical spectrum depending on the amount of the hemorrhage was seen, ranging from mild anemia with no symptoms (four cases), hypovolemic shock (one case), respiratory distress syndrome (two cases) and maladjustment to extra-uterine life (one case). There was one death at 48 hours after birth; one infant survived with severe encephalopathy. CONCLUSION: These results indicate that it is mandatory to carry out a Kleihauer test whenever a high suspicious index of FMH is faced or an unexplained neonatal anemia is found.     

Cortisol differentially regulates pituitary-adrenal function in the sheep fetus after disconnection of the hypothalamus and pituitary

We have investigated the effects of a 5 day infusion of cortisol into fetal sheep, in which the hypothalamus and pituitary were surgically disconnected (HPD), on fetal pituitary-adrenal function. Fetal HPD and vascular catheterization were carried out at between 104 and 124 days gestation. Cortisol was administered (3.5 mg 24 h-1) for 120 h between 134 and 140 days (HPD + F group; n = 5) and saline was administered during the same gestational age range to HPD (HPD group; n = 12) and intact fetal sheep (Intact group; n = 6). Cortisol infusion into the HPD fetal sheep did not suppress the mRNA levels for Proopiomelanocortin (POMC) in the fetal anterior pituitary at 139/140 days gestation (POMC mRNA: 18S rRNA: Intact 0.40 +/- 0.05; HPD 0.56 +/- 0.07; HPD + F 0.49 +/- 0.07). Similarly, there was no significant effect of either HPD or cortisol infusion on the plasma concentrations of immunoreactive (ir) ACTH or ACTH(1-39). The adrenal: fetal body weight ratio was significantly higher, however, in the HPD + F (88.4 +/- 8.7 mg kg-1) and Intact groups (84.1 +/- 5.6 mg kg-1) when compared with the HPD fetal sheep (63.7 +/- 5.4 mg kg-1). The ratio of total IGF-II mRNA: 18S rRNA was similar in the adrenals of the Intact (0.48 +/- 0.09), HPD (0.78 +/- 0.09) and HPD + F (0.71 +/- 0.11) groups. The ratios of CYPIIA1, 3 beta-HSD and CYP21A1 mRNA: 18S rRNA were significantly lower in adrenals from the HPD group when compared to those in the Intact group and were not restored to normal by cortisol infusion. We have therefore demonstrated that cortisol does not act directly at the fetal pituitary to suppress POMC synthesis or ACTH secretion in late gestation. Cortisol does, however, stimulate fetal adrenal growth after HPD in the absence of any effects on adrenal IGF-II or steroidogenic enzyme mRNA levels. The data provide evidence that an intact hypothalamic-pituitary axis and cortisol each play an important role in the stimulation of adrenal growth and steroidogenesis which occurs during the last 10-15 days of gestation in the sheep.     

Early prognostic ultrasonographic indices in pregnancy with fetal cystic hygroma

OBJECTIVE: Aim of this study was the correlation of same early ultrasonographic signs with fetal karyotype, prognosis of pregnancy and neonatal outcome. EXPERIMENTAL DESIGN: Volume of cystic hygroma and presence of septations are correlated with fetal karyotype and an ultrasonographic follow-up was carried out during pregnancy. Details concerning neonatal outcome were recorded at delivery. PATIENTS: Diagnosis was performed in 13 patients between 8.3 to 16.5 weeks' gestation referred to our center for prenatal diagnosis or for obstetric reasons. METHOD: Ultrasonographic examinations were performed using 5.0 and 6.0 MHz endovaginal convex probes. SURVEYS: Hygroma was diagnosed as a cystic dilatation in the nuchal region larger than 3 mm in diameter in the anterolateral aspects. The volume was calculated considering the lesion as spherical and using the standard formula for an ellipsoid volume; the presence of septations was considered. RESULTS: A volume greater than 70 cc3 and the presence of septations demonstrated a strictly correlation with fetal karyotype, evolution of the features, pregnancy and neonatal outcome. CONCLUSIONS: Prognosis varies depending on fetal karyotype, volume, presence of septations and other associated malformations. The volume of the hygroma and the presence of septa are associated with higher incidence of chromosomal diseases and a poorer fetal prognosis.     

The role of weight concern and self-efficacy in smoking cessation and weight gain among smokers in a clinic-based cessation program

We have previously reported that Vicia graminea lectin (VGA)- and Vicia unijuga lectin (VUA)-binding glycoproteins (Vgu glycoproteins), malignant tumor-associated antigens, exist in human meconium and amniotic fluid. To examine the origin of Vgu glycoprotein, their presence, some of their chemical and serological properties and their biosynthesis in the human fetal membrane, amnion and chorion laeve and accompanying membrane cells were examined. Perchloric acid-soluble fractions were prepared from human amnion and chorion laeve, after which VUA-binding components (Vgu glycoproteins) were separated by HPLC and affinity chromatography using immobilized VUA. Biosynthesis of the antigens in primary cultured cells prepared from the amnion and chorion laeve were examined by pulse-labeling and immunoprecipitation using immobilized VUA and compared with those in cultured human cancer cells. The results indicated that the serological properties of VUA-binding components in fetal membranes were similar to those of meconium and amniotic fluid, that many molecular species of VUA-binding components were synthesized in amnion and chorion laeve cells and that about 40-50% of antigens synthesized are secreted from cells while antigens synthesized in cultured cancer cells human were hardly secreted with more than 95% of the antigens remaining in the cells. From these results, we concluded that a large part of Vgu glycoproteins found in amniotic fluid is synthesized in cells of the amnion and chorion laeve and secreted into the fluid, and that Vgu glycoproteins synthesized in cancer cells were not secreted, rather they were retained in the cells.     

Two cases of cystic fibrosis in Japanese/German twins

We report a case of twins with cystic fibrosis. The twins are of mixed parentage, having a Japanese mother and a German father. One case presented with meconium ileus as a neonate. The other twin was relatively healthy until the age of 6, when she was first hospitalized with a diagnosis of pulmonary aspergillosis. They have been receiving standard therapies in the United States, including digestive enzymes, vitamins, and periodic antibiotics. At the age of 19 both patients received home intravenous antibiotic therapy, and began to use an inhaled DNase at the age of 20. When the patients were 19 they were screened for the common mutations causing cystic fibrosis, and the delta F508 CFTR mutation was identified. We analyzed their CFTR genes, as well as those of their Japanese mother and grandmother. Missense mutations at exon 7 (R347H) and exon 16 were found (D979A) in the twins and in their Japanese mother.     

Prostaglandins and thromboxanes in amniotic fluid during rivanol-induced abortion and labour

Abortion or delivery were induced by extra-amniotic instillation of Rivanol during the second trimester in twelve patients and during the third trimester in two patients with fetal death and one patient with fetal acrania. Serial sampling of amniotic fluid was performed through a transabdominal catheter and the levels of free arachidonic acid (AA), prostaglandin F2 alpha (PGF2 alpha), prostaglandin E2 (PGE2), 6-keto-prostaglandin F1 alpha (6-keto-PGF1 alpha) and thromboxane B2 (TXB2) were determined. The levels of AA, PGF2 alpha, PGE2, 6-keto-PGF1 alpha and TXB2 in amniotic fluid increased significantly during induction with the exception of AA in fetal death which was high and remained constant during induction. Furthermore, PGF2 alpha, 6-keto-PGF1 alpha and TXB2 were all significantly correlated to AA. These observations suggested that free AA is released during Rivanol-induction of abortion and labour giving an increased synthesis of PGF2 alpha, PGE2 prostacyclin and thromboxane A2 in the fetal membranes and the decidua but not in the fetus. This increase might be relevant for the initiation and progress of abortion and labour in these patients.     

Potentially asphyxiating conditions and spastic cerebral palsy in infants of normal birth weight

OBJECTIVE: Our purpose was to examine the association of cerebral palsy with conditions that can interrupt oxygen supply to the fetus as a primary pathogenetic event. STUDY DESIGN: A population-based case-control study was performed in four California counties, 1983 through 1985, comparing birth records of 46 children with disabling spastic cerebral palsy without recognized prenatal brain lesions and 378 randomly selected control children weighing > or = 2500 g at birth and surviving to age 3 years. RESULTS: Eight of 46 children with otherwise unexplained spastic cerebral palsy, all eight with quadriplegic cerebral palsy, and 15 of 378 controls had births complicated by tight nuchal cord (odds ratio for quadriplegia 18, 95% confidence interval 6.2 to 48). Other potentially asphyxiating conditions were uncommon and none was associated with spastic diplegia or hemiplegia. Level of care, oxytocin for augmentation of labor, and surgical delivery did not alter the association of potentially asphyxiating conditions with spastic quadriplegia. Intrapartum indicators of fetal stress, including meconium in amniotic fluid and fetal monitoring abnormalities, were common and did not distinguish children with quadriplegia who had potentially asphyxiating conditions from controls with such conditions. CONCLUSION: Potentially asphyxiating conditions, chiefly tight nuchal cord, were associated with an appreciable proportion of unexplained spastic quadriplegia but not with diplegia or hemiplegia. Intrapartum abnormalities were common both in children with cerebral palsy and controls and did not distinguish between them.     

Dependence of aortic pulse wave assessments on behavioural state in normal term fetus

To investigate any influence of behavioural states on the pulse waves in the descending aorta, 21 human fetuses were studied in utero in uncomplicated gestation at the age of 36-41 weeks. The fetal behavioural states were identified using two real-time scanners and one cardiotocograph. The aortic waveform data and pulse wave velocity (PWV) were recorded by means of two double phase-locking echo-trackers. The PWV of the fetal aorta was significantly lower in fetal behavioural state (FBS) 2F than in FBS 1F, when the fetus was apnoeic, and was also reduced in both states during fetal breathing. The calculated pulse pressure showed the same trend as the PWV. The fetal aortic end diastolic diameter and the pulse amplitude did not alter, when the two states changed. Our data suggest that the central haemodynamics in term fetuses are independently influenced by their behavioural state as well as by fetal breathing. The study of pulse waves in the fetal aorta should preferably be performed during apnoea in state 1F, when neither gross body movements nor breathing movements disturb the recording.