The work of the American emergency physician

OBJECTIVE: To compare gestational age (GA) calculated from oocyte retrieval and from ultrasound measurements in pregnancies after in vitro fertilization (IVF). DESIGN: In a retrospective study of 253 women with singleton and 84 women with twin pregnancies conceived from IVF, GA calculated from the day of oocyte retrieval was compared with GA calculated in the second trimester of pregnancy from ultrasound measurements of biparietal diameter (BPD) and femur length (FL). RESULTS: For singletons, the mean GA calculated from ultrasound measurements was significantly shorter than the mean GA estimated from the day of oocyte retrieval. The mean difference was 1.9 days (SD 3.3; 95% CI 1.5-2.4) if only BPD was used and 2.1 days (SD 2.1; 95% CI 1.6-2.5) if BPD and FL were combined. For twins, the mean GA calculated from ultrasound measurements was also significantly shorter than the mean GA calculated from the day of oocyte retrieval. The mean difference was 1.4 days (SD 2.7; 95% CI 1.0-1.8) if BPD was used and 1.6 days (SD 2.5; 95% CI 1.2-2.0) if BPD and FL were combined. CONCLUSIONS: In IVF pregnancies, term prediction using ultrasound in the second trimester is reliable and may reduce the number of pregnancies subsequently classified as post-term, thus avoiding unnecessary obstetric interventions.     

Birth weight prediction by B-type ultrasonic measurement of fetal transverse cerebellar diameter

The fetal transverse cerebellar diameter (CD), biparietal diameter(BPD), abdominal circumference (AC) and femur length(FL) were measured by B-type ultrasonography on 222 normal pregnant women with one week before the expected date of confinement (EDC) and their correlations with birth weight of newborns were computerized. Single factorial analyses showed the best correlation was between CD and birth weight (R = 0.913 4) where as the R value for birth weight and AC, BPD, FL was 0.739 5, 0.612 5, 0.347 6 respectively. The F value of CD on stepwise regression analysis was the highest (F = 1001.95) while that of AC and BPD was 4.55, 4.36 respectively (P < 0.05). Then the regression equations of single double and triple factors were established. It was confirmed by clinical findings that the equation of log(BW) = 2,8844 + 0.01416 x CD was the most reliable one in predicting the birth weight. The error rate was less than 10% in 96% of the newborns.     

Ultrasound evaluation of the width of the fetal nose

The aim of the study was to construct a normal range for the width of the fetal nose during gestation. The study group included 229 healthy pregnant women with normal singleton pregnancies at 15-42 weeks of gestation. The ultrasound measurements were taken at the level of the lower border of the ala nasi, using the modified coronal view. Routine biometric measurements were obtained from the participants, including biparietal diameter, head and abdominal circumferences, cerebellum and femur lengths. Our results were used to construct objective measurements of the fetal nasal width across all gestational ages. We conclude that the nasal width can be easily measured from 15 weeks of gestation using the modified coronal view. A linear growth relationship was found between nasal width and gestational age, biparietal diameter, head and abdominal circumferences, and transcerebellar and femoral lengths. We feel that such measurements may prove useful in the diagnosis of cases at high risk for fetal facial abnormalities.     

Experience with the Ultrex and Ultrex Plus inflatable penile prosthesis: new implantation techniques and surgical outcome

OBJECTIVE: To construct nomograms of the size of the fetal orbit and lens during gestation. SUBJECTS: The study group included 349 normal pregnant women at 14-36 weeks' gestation. METHODS: Routine biometric measurements were obtained in all the participants; these included biparietal diameter, head and abdominal circumferences, measurements of the long bones and the diameters of the fetal orbit and lens. The orbital and lens circumference measurements were also related to gestational ages. RESULTS: A linear growth function was observed between gestational age (GA) and orbital diameter (r = 0.94; p < 0.00001; y = -0.66 + 0.5 x GA), orbital circumference (r = 0.94; p < 0.00001; y = -2.1 + 1.5 x GA) and orbital area (r = 0.94; p < 0.00001; y = -98.1 + 8.3 x GA). Significant correlation was also found between femoral length (FL) and orbital diameter (r = 0.95; p < 0.00001; y = 3.3 + 1.9 x FL), orbital circumference (r = 0.95; p < 0.00001; y = 10.3 + 5.9 x FL) and orbital area (r = 0.93; p < 0.00001; y = -28.2 + 32.2 x FL). A linear growth function was observed between orbital circumference and biparietal diameter (r = 0.94; p < 0.00001) and head circumference (r = 0.95; p < 0.00001). A linear growth function was also observed between gestational age and the diameter of the lens (r = 0.89; p < 0.00001; y = 0.88 + 1.4 x GA) the circumference of the lens (r = 0.89; p < 0.00001; y = 2.78 + 0.4 x GA) and the area of the lens (r = 0.89; p < 0.00001; y = -7.95 + 1.0 x GA). The correlation was found between the ratios of the diameters, circumferences and areas of the lens and the orbit. CONCLUSIONS: These results provide normative data of the growth of the fetal orbit and lens and may aid future studies relating to fetal eye anomalies.     

Fistula-in-Ano: perineal fistula of intra-abdominal or intrapelvic origin simulating fistula-in-ano--report of seven cases

In 219 normal pregnancies between 28 and 42 weeks the relationships of different ultrasound measurements of the fetal head and the fetal body to the gestational age were determined in order to improve the accurate diagnosis of fetal maturity during the last trimester of pregnancy. With the A and B ultrasound apparatus of Kretz, the biparietal diameter was determined by the A mode, the fronto occipital plane and the largest abdominal diamter were determined by the B scan. The following ultrasound measurements were taken: the two horizontal and transverse diameters, the circumferences and the planes. The abdominal measurements showed a higher rate of growth, compared to the cranial measurements a lesser rate of growth retardation and a higher variation of the normals. The correlation of the abdominal measurements with the gestational age was worse than that of the cranial measurements. Wth the exception of the biparietal diameter in the A mode, the mean diameters of the cranial and abdominal measurements gave better results than the single diameters. Circumference and surface measurements showed no advantages. The best results were obtained by combined fetal head and body measurements using the summation of the biparietal diameter in the A mode and the mean abdominal diameter in the B scan.     

Biparietal diameter: a useful measure for determining gestational age of human abortuses

BACKGROUND: The crown-rump length is conventionally used to determine the age of human abortuses. However, it is not reliable as it is dependent on the positioning of the conceptus. We compared this with the biparietal diameter and foot length for determining the gestational age. METHODS: Different measurements, commonly used to assess gestational age, were measured in 146 human abortuses for which an accurate obstetric history could not be elicited. Measurements taken were crown-rump length, biparietal diameter and foot length. These were correlated with the observations at antenatal examinations before finalizing the approximate age. RESULTS: Multiple regression analysis of the data indicated that of the three measurements, the biparietal diameter was the most reliable for determining foetal gestational age between 8 and 26 weeks. The age determined with the biparietal diameter correlated well with that of abortuses with an accurate obstetric history. CONCLUSION: The biparietal diameter of a human foetus may be used to determine its age if the obstetric history regarding the period of gestation is vague or not available.     

How accurate is fetal biometry in the assessment of fetal age?

OBJECTIVE: The purpose of the study was to assess the accuracy of fetal biometry in the midtrimester of pregnancy in the assignment of fetal age. STUDY DESIGN: A total of 152 singleton, 67 twin, and 19 triplet gestations resulting from in vitro fertilization with ultrasonographic fetal biometry from 14 to 22 weeks made up the study population. A gestational age prediction equation was derived from singletons with the use of stepwise linear regression. This equation was compared with 38 previously published equations and then applied to the twin and triplet populations. RESULTS: Head circumference was the best predictor of gestational age (random error [SD] 3.77 days). Addition of abdominal circumference and femur length to head circumference improved the accuracy of the dating equation (random error 3.35 days). Most dating formulas had systematic errors of <1 week. The systematic error was -0.32 day for averaging the singleton-based predictions for twins and -1.26 days for triplets. CONCLUSIONS: Gestational age assessment with the use of fetal biometry from 14 to 22 weeks is accurate for singleton, twin, and triplet gestations.     

A comparison of sonographic growth curves of triplet and twin fetuses

Sonographic growth curves of 47 normal triplet pregnancies were compared with those of 71 uncomplicated twin gestations. Starting from the 25th week, the biparietal diameter in triplets was found to lag progressively compared with that of twins, reaching a mean difference of 2 weeks at 36 weeks gestation. Similarly, a significant difference was found between the femur length and head to abdomen circumference ratio growth curves of triplets and twins. It is concluded that as pregnancy continues from the 25th to the 36th gestational week, there is a significant delay in the growth patterns of normal triplet pregnancies compared with twin gestations.     

Ontogenetic changes in genetic regulation of fetal morphometrics in baboons (Papio hamadryas subspp.)

It is known that different genes are expressed during ontogeny; however, it is unclear how variation in that expression is associated with changes in growth patterns. The objective of this study is to assess how genetic variation in fetal morphology changes with ontogeny in baboons. Longitudinal measures of the head and femur (60 to 180 days gestation) were available for 892 pregnancies. We used a genetic model that allowed both the genetic and environmental variances (sigma 2G and sigma 2E) to change with age and estimated genetic and environmental correlations (rho G and rho E) between measurements at different ages. The results indicate a significant increase in the genetic variance for biparietal diameter and femur length but not for head circumference and fronto-occipital diameter. The rho G estimates for all measures decreased as the age between measures increased from 0 to 120 days, indicating that different groups of genes are expressed early in gestation and late in gestation. The rho E estimates dropped rapidly from 1 to 0 for all measures, indicating temporally localized environmental influences on fetal growth. Thus fetal morphometrics are significantly heritable and those genes that influence them show age-specific expression during ontogeny.     

Sonographic evaluation of fetal growth: growth rate variability as a function of the interval between examinations

OBJECTIVE: Fetal growth rates determined on the basis of findings at two separate sonographic examinations can be used to detect growth abnormalities. This article determines the relationship between the length of the interval between examinations and the associated variability in measured fetal growth rates. MATERIALS AND METHODS: We analyzed 1479 fetal measurements of the biparietal diameter, average abdominal diameter, and femur length from 539 normal pregnancies. Mean growth rates were computed as functions of gestational age. The standard deviation of the growth rate was computed as a function of the interval between examinations. RESULTS: The standard deviation of fetal growth rates is relatively constant when the interval between examinations is 8-10 weeks or more, but increases substantially when the interval is fewer than 6 weeks. CONCLUSION: From a purely statistical point of view, the optimal interval for assessment of fetal growth rates is 8-10 weeks or more. Shorter intervals, however, usually are mandated by the clinical situation. Correction factors can be used to determine the standard deviations and associated confidence intervals for fetal growth measured over a period of fewer than 10 weeks.     

Partial and complete correlations of fetal maturity with ultrasonographic and enzymatic measurements

The computer-aided enzymatic and ultrasonographic method of pregnancy monitoring takes into account ultrasound measurements of fetal parameters (BPD, HC, AC, FL) and oxytocinase (CAP1) and isooxytocinase (CAP2) levels in maternal blood. In this paper we decided to verify which one of this values have the major influence on fetal maturity prediction. 385 pregnancies, after sterility treatment, were studied where ultrasound measurements and enzymes levels were estimated simultaneously as well as current fetal maturity were established using computer-aided method by M. Klimek. There are high sample correlations between current fetal maturity and the number of remaining days to labor (r = -0.8) as well as ultrasound measurements (BPD r = 0.87, HC r = 0.89, AC r = 0.90, FL r = 0.81). Fetal maturity correlations with enzymatic values (CAP1, CAP2) were smaller 0.55, 0.52 respectively. The partial correlation pictures this relations much stronger -0.29, 0.28, 0.22, 0.30, 0.46, -0.06, 0.13 respectively.     

A case of successful hypospadias repair without infection using recombinant human granulocyte-colony stimulating factor (rhG-CSF) for idiopathic neutropenia

OBJECTIVES: To establish normative data for the width of the fetal cavum septi pellucidi at various gestational ages. SUBJECTS AND METHODS: A total of 608 consecutive fetuses between 19 and 42 gestational weeks were included in this prospective study. The largest width of the cavum septi pellucidi was measured by two-dimensional ultrasound. Piecewise regression analysis was used to study the relationships between the width of the fetal cavum septi pellucidi, gestational age and biparietal diameter. RESULTS: The fetal cavum septi pellucidi width increased gradually between 19 and 27 weeks of gestation and then plateaued between 28 weeks and term. Regression analysis revealed significant associations between cavum septi pellucidi width and gestational age, and cavum septi pellucidi width and biparietal diameter. CONCLUSIONS: The present study provides normative data for fetal cavum septi pellucidi width and useful information about the development of the midline brain structure in the fetus.     

Ultrasonographic examination of intrauterine growth for multiple fetal dimensions in a Chinese population. Central-South China Fetal Growth Study Group

OBJECTIVE: We sought to construct an ultrasonography-based growth curve in a Chinese population. STUDY DESIGN: Routine ultrasonographic examination was performed in 5496 normal pregnancies (>95% first births) in five obstetric ultrasonography laboratories in Central-South China from January 1, 1992, to December 31, 1993. RESULTS: All the fetal growth measures increased with gestational age, whereas the ratios either decreased or remained constant across gestation. Biparietal diameter and cerebral hemispheric width were higher at early gestational ages, whereas femur length, thoracic circumference, and abdominal circumference were lower at later gestational ages in our study than in previous studies. The ratio of lateral ventricular width/cerebral hemispheric width was lower at an early gestational age but higher in later gestational ages in our study. CONCLUSIONS: A different standard of ultrasonography-based fetal growth is needed for different populations. The ultrasonography-based growth curve constructed in this large Chinese population provides an additional tool for the evaluation of fetal growth and development.     

Fetal biparietal diameter and birth weight. An interpopulation comparison

Data on the biparietal diameter (BPD), determined ultrasonically, of the full-term South African Negroid fetus are presented. Population differences in the absolute value of the BPD and the linear regression of birth weight on the biparietal dimension are emphasised. The possible biological explanations for these differences are discussed.     

First- and second-trimester hemoglobin levels. Relation to birth weight and gestational age

The computerized records of 3074 women who were delivered during the period 1987-1990 were analysed. We studied possible relations of birth weight and gestational age to maternal first- and second-trimester hemoglobin levels. Birth weight and gestational age were taken as outcome variables in a multiple stepwise regression analysis, including factors that might interact with hemoglobin levels. A strong independent inverse correlation between the lowest second-trimester hemoglobin and birth weight was observed. First-trimester hemoglobin levels explained little with regard to birth weight, but had a small negative correlation to gestational age. For gestational age < 259 days we found a strong positive correlation between the first- to second-trimester decrease in hemoglobin and birth weight.     

Severe acute pancreatitis: pathophysiologic mechanisms underlying pancreatic necrosis and remote organ damage

In a non-selected population comprising 15,241 women, an evaluation was performed of the ultrasonic measurement of the biparietal diameter compared with a reliable last menstrual period as the basis for estimation of the day of delivery. In women with a reliable menstrual history and spontaneous onset of labor, the ultrasound estimate was the significantly better predictor of the day of delivery in 52% of cases, and the last menstrual period estimate was the better predictor in 46% of cases. The percentages of women who delivered within 7 days of the predicted day were 61 and 56% for the ultrasound and the last menstrual period estimations, respectively. There was a significantly narrower distribution of births according to the ultrasound estimate (p < 0.001). The proportion of estimated postterm births was 4% using the ultrasound method and 10% using the last menstrual period method (p < 0.001). Even when the difference between the methods in predicting the day of delivery was less than 7 days, the ultrasound method was better than the last menstrual period method. It is concluded that ultrasonic measurement of the biparietal diameter between 15 and 22 weeks of pregnancy is the best method for the estimation of the day of delivery and should be used as a routine procedure.     

Undetectable maternal serum unconjugated estriol levels in the second trimester: risk of perinatal complications associated with placental sulfatase deficiency

OBJECTIVE: Our purpose was to determine the prevalence of undetectably low second-trimester maternal serum unconjugated estriol levels and the association with increased perinatal morbidity or mortality in pregnancies at risk for placental sulfatase deficiency. STUDY DESIGN: Nine centers in New England identified singleton pregnancies with undetectably low unconjugated estriol levels. Each unexplained case was matched with four controls; pregnancy outcome information was sought. RESULTS: Among 130,295 pregnancies surveyed, undetectably low unconjugated estriol levels were identified in 167 (13/10,000). Explanations included fetal death (53), overestimated gestational age (50), nonpregnancy (12), and chromosome abnormalities (5). The 41 unexplained cases were compared with 163 matched controls. Male offspring were more frequent (85%) among cases than among controls (55%). Although rates of perinatal complications were not significantly different, primary cesarean sections occurred about twice as often among cases. No perinatal deaths occurred. CONCLUSIONS: Neither severity of symptoms nor perinatal morbidity or mortality currently warrant routine interpretation of unexplained undetectably low unconjugated estriol levels as a marker for placental sulfatase deficiency.     

Quantitative study on the effect of osthole on proximal tibiae in ovariectomized (OVX) rats

OBJECTIVE: To determine if a correlation exists between the level of maternal serum alpha-fetoprotein (MSAFP) elevation and the rate of adverse pregnancy outcome, to examine the timing of pregnancies ending in fetal or neonatal death, and to develop a protocol for antepartum surveillance in an effort to prevent these adverse outcomes. STUDY DESIGN: Singleton pregnancies with a single second-trimester elevated MSAFP > or = 2.0 multiples of the median (MoM) were eligible if a targeted ultrasound evaluation (< 24 weeks) was in agreement with the dates and no fetoplacental anomaly was detected. Three groups were established based on the second-trimester MSAFP elevation: 2.0-2.49, 2.5-2.99 and > or = 3.0 MoM. RESULTS: Among the 383 patients enrolled, delivery data were available on 333 infants. Stratified by MSAFP elevations of 2.0-2.49, 2.5-2.99 and > or = 3.0 MoM, the rates of adverse pregnancy outcome were: (1) preterm birth: 14.3%, 15.6%, 20.3%; (2) small for gestational age at birth: 7.4%, 11.1%, 22.2%; and (3) perinatal deaths (neonatal and fetal): 2.6%, 3.3%, 5.6%. Seven pregnancy losses (three neonatal and four fetal deaths) occurred prior to 28 weeks. Of these seven, six fetuses exhibited intrauterine growth retardation by 23-26 weeks' gestation, and five of six were associated with MSAFP levels > or = 2.5 MoM. Four losses (two neonatal and two fetal deaths) occurred after 28 weeks. Of these, three involved structurally normal infants with normal growth who died after 34 weeks. All three of these pregnancies exhibited MSAFP elevations < 2.5 MoM. CONCLUSION: In pregnancies with an unexplained elevated second-trimester MSAFP, the rate of adverse pregnancy outcomes is increased with higher elevations. Any proposed program to improve pregnancy outcome in patients with unexplained MSAFP elevations must include efforts aimed at preventing preterm delivery, repeat ultrasound at 24-26 weeks to rule out early-onset intrauterine growth retardation in pregnancies with elevations > or = 2.5 MoM and fetal biophysical monitoring, even in normally grown fetuses, instituted at 32 weeks to detect fetuses at risk for intrauterine death.     

Evaluation of T-lymphocytes in esophageal mucosal biopsies

OBJECTIVE: To modify and improve a protocol for surveillance of patients presenting for routine elective abortion services. METHODS: Six hundred seventy-four women presenting for routine elective first-trimester abortions were studied. All were 84 or fewer days after the last menstrual period, had no history of bleeding, and had positive urine pregnancy tests. Each woman was scanned initially with an empty-bladder transabdominal technique. If no sac was seen, endovaginal ultrasonography was performed. All terminations had modified gross examination of tissue (3x magnification) as well as staining for microscopic analysis. RESULTS: Six hundred twelve patients (90.8%) demonstrated intrauterine gestations on transabdominal ultrasound, 595 of which were 12 or fewer weeks. Suction and sharp curettage and examination of tissue revealed products of conception in all. Seventeen subjects (2.5%) were found to be 13 or more weeks despite bimanual examinations and last menstrual period suggesting 12 or fewer weeks. Sixty-two patients had no sac seen on transabdominal ultrasound, 34 of whom had definitive intrauterine gestations on endovaginal ultrasound. Curettage revealed chorionic villi in all. Two had unruptured definitive ectopic pregnancies seen on endovaginal ultrasound. Twenty-one women with no sac seen on endovaginal ultrasound underwent curettage as the next step in triage; chorionic villi proved an intrauterine gestation in 17. The additional four had decidua only on pathology. Rising hCG levels in two of these four led to a diagnosis of ectopic pregnancy, whereas falling hCG levels in the other two led to a presumptive diagnosis of complete abortion, possibly tubal pregnancy in light of the lack of vaginal bleeding. CONCLUSION: Pre-abortion sonography eliminates inadvertent second-trimester cases, and immediate postoperative examination of curettage material expedites the diagnosis of ectopic pregnancy when present.