A comparison of the shake test, optical density, L/S ratio (planimetric and stechiometric) and PG for the assessment of fetal lung maturity

Our aim was to determine the diagnostic accuracy and reliability of four tests for the assessment of fetal lung maturity (FLM): shake test, optical density at 650 nm (OD650), lecithin to sphingomyelin ratio (L/S) by planimetry and stechiometry, and presence of phosphatydylglycerol. Amniotic fluid was obtained from 74 patients at various gestational ages. The shake test and the OD650 were performed according to published methods L/S was determined by TLC (thin-layer chromatography) and the ratio assessed by planimetry and stechiometrically by measurement of organic phosphorus from the chromatographic spots. PG was assessed similarly by TLC. When correlated with gestational age at amniocentesis, all tests correlated positively: shake test (r = 0.46, p < 0.005); OD650 (r = 0.31, p < 0.005); planimetric L/S (r = 0.77, p < 0.005); stechiometric L/S (r = 0.52, p < 0.005) and PG (r = 0.54, p < 0.005). The diagnostic accuracy of each test was as follows: the shake test and the OD650 had a sensitivity of 50%, while the steciometric L/S had a sensitivity of 75%, the planimetric L/S and the presence of PG were 100%. All four tests demonstrated a specificity greater than 64%, the highest for the PG presence being (83%) and the shake test (86%). Predictive negative values for lung maturity were > 93% for all tests, with the highest for the planimetric L/S and presence of PG being (100%). The study confirms that the determination of L/S ratio is still superior to other tests in terms of overall diagnostic accuracy. In addition, it was found that presence of PG was highly associated with the absence of respiratory complications in the newborn.     

Is fluorescence polarization reliable and cost efficient in a fetal lung maturity cascade?

OBJECTIVE: The objective of the study was to compare the accuracy of the TDxFLM test (Abbott Laboratories) with the fetal lung maturity cascade (shake, foam stability index, lecithin/sphingomyelin tests) and to determine whether the TDxFLM test could increase the efficiency and reduce the cost without decreasing the reliability of a cascade. STUDY DESIGN: A prospective, single-blinded study was conducted. Uncontaminated amniotic fluid obtained by transabdominal amniocentesis for fetal lung maturity assessment was evaluated with use of the fetal lung maturity cascade and the TDxFLM test. At study completion the results of the TDxFLM test were compared with those of the maturity cascade with regard to hyaline membrane disease, which was defined by strict clinical and radiographic parameters. A power analysis was performed requiring a sample size of 100 infants delivered within 72 hours of amniocentesis with use of the 95% confidence interval. RESULTS: A total of 115 cases had a full maturity cascade performed, of which 40 (35%) had a positive shake or foam stability index and 75 cases required progression to a lecithin/sphingomyelin ratio because of negative results. The TDxFLM test result was > or = 70 mg/gm in 42 (37%) of these 115. One hundred eight newborns were delivered within 72 hours of the amniocentesis; 65% (71) of these were between 30 and 37 weeks of estimated gestational age. There were 7 cases of hyaline membrane disease in the 108 newborns. Of these 108, 87 had a mature original cascade versus 85 mature tests with use of a proposed TDxFLM test-lecithin/sphingomyelin ratio cascade with one case of respiratory distress syndrome and hyaline membrane disease. The sensitivity, specificity, and positive and negative predictive values for the original cascade were 86%, 84%, 27%, and 99%, respectively; for the proposed TDxFLM test-lecithin/sphingomyelin ratio cascade the values were 86%, 83%, 26%, and 99%, respectively. The TDxFLM test-lecithin/sphingomyelin ratio cascade would have resulted in a cost reduction of 24% with no significant delay in turnaround time. CONCLUSION: The TDxFLM test appears to be a reliable and accurate assessment of fetal lung maturity. Furthermore, by replacing the shake and foam stability index portion of the cascade with the TDxFLM test, a cost savings of 24% would occur without a decrease in safety. These results also reveal that it could enhance patient care and be cost efficient for institutions not currently doing fetal pulmonary maturity testing to undertake use of the TDxFLM test and to only send out specimens for a lecithin/sphingomyelin ratio that have an initial immature TDxFLM test result (< 70 mg/gm). Likewise, institutions currently only performing a lecithin/sphingomyelin ratio may consider a TDxFLM test-lecithin sphingomyelin ratio cascade. Although direct costs would increase, they would be counterbalanced by a significant reduction in laboratory technician time.     

Amniotic fluid and fetal maturity

The lecithin/sphingomyelin ratio in amniotic fluid is a method of predicting fetal lung maturity. The L/H ratios in certain high risk pregnancies are poorly correlated with the shake test. The L/S ratios in drug addiction methadone pregnancies and diabetic pregnancies do not have a high degree of correlation with normal L/S ratios after 36 weeks of gestation and are often low.     

Spectrum of immunodeficiency in HIV-1-infected patients with pulmonary tuberculosis in Zaire

Tuberculosis (TB) is the most common opportunistic infection in African patients who die from AIDS, yet the stage of immunodeficiency at which TB develops is uncertain. We studied the immune status of HIV-infected outpatients with pulmonary TB in relation to their clinical presentation in a cross-sectional study of 216 HIV-seropositive and 146 HIV-seronegative ambulatory incident cases of smear-positive and culture-positive pulmonary TB in Kinshasa, Zaire. HIV-seropositive and seronegative patients had median CD4 lymphocyte counts of 316.5/microL and 830.5/microL, respectively. Of the HIV-seropositive patients, 32.9% had less than 200 CD4 lymphocytes/microL, 37% between 200 and 499, and 30.1% 500 or more. Clinical AIDS, as defined by the WHO clinical case-definition or a modified version, was of similar limited use as a predictor of immunodeficiency. Among HIV-seropositive patients, oral candidosis, lymphopenia, a negative tuberculin purified protein derivative test, and cutaneous anergy were strongly associated with CD4 counts of less than 200/microL, and seemed to be better markers of immune dysfunction. We conclude that pulmonary TB develops across a broad spectrum of HIV-induced immunodeficiency and that a diagnosis of pulmonary TB is of limited use as a marker of stage of HIV disease in African HIV-infected outpatients.     

Comparison of two tests and absorbance at 650 nm for assessing fetal lung maturity

The clinical performance of three rapidly performed tests--tap test, TDx Fetal Lung Maturity and amniotic fluid absorbance at 650 nm--in predicting fetal lung maturity were evaluated in 300 samples of clear amniotic fluid. In all cases, delivery occurred within three days of sample collection. Of the 300 newborns, 44 developed respiratory distress syndrome. For the tap test, the sensitivity (95.4%), specificity (82.8%), and predictive value for maturity (99.7%) and immaturity (48.9%) were comparable to those of the TDx fetal lung maturity test: sensitivity of 100%, specificity of 88.3%, and predictive value for maturity of 100% and immaturity of 53.1%. The specificity (68.4%) and predictive value for immaturity (34.7%) of amniotic fluid absorbance at 650 nm were significantly lower than for the TDx and tap tests, whereas no significant difference was found for sensitivity and prediction of maturity between amniotic fluid absorbance at 650 nm and the TDx and tap tests. Both the tap and the TDx tests appear to be useful in antenatal assessment of fetal lung maturity in terms of reliability, rapidity and uniformity.     

Antiphospholipid antibodies syndrome

OBJECTIVE: To measure the prognostic utility of helper T-cell (CD4) counts in human immunodeficiency virus (HIV)-infected patients undergoing major abdominal surgery. DESIGN: Retrospective case series. SETTING: Three university-affiliated hospitals. PATIENTS: Forty-three HIV-infected patients undergoing major abdominal surgery. MAIN OUTCOME MEASURES: Morbidity and mortality rates with respect to CD4 cell counts. RESULTS: Nineteen of 32 patients who had CD4 cell counts less than 0.20 X 10(9)/L (200 cells/microL) suffered major complications compared with 2 of 11 patients who had CD4 cell counts greater than 0.20 x 10(9)/L (200 cells/microL) (P=.03). Perioperative mortality was 38% for patients with CD4 cell counts less than 0.20 x 10(9)/L, and was 9% for those with CD4 cell counts greater than 0.20 x 10(9)/L (P=.13). Six months postoperatively, mortality rates were 47% and 9%, respectively (P=.03). Of patients with septic processes perioperatively (n=12), mortality was 75%, and was 19% (P=.009) for those with nonseptic processes (n=31). Nine patients had HIV-related intra-abdominal pathologic conditions at laparotomy. Mortality was 56% perioperatively (P=.13) and 88% after 6 months (P=.001). Sixty-eight percent of patients who received blood product transfusions developed complications, whereas only 7% of those who did not receive transfusions developed complications (P<.001). Overall mortality and morbidity rates were 37% and 49%, respectively. Patients with morbidity had lower CD4 cell counts (median, 0.034 x 10(9)/L) than those without complications (median, 0.102 x 10(9)/L) (P=.02). Similarly, patients who died had lower CD4 cell counts (median, 0.031 x 10(9)/L vs 0.088 x 10(9)/L) (P=.05). CONCLUSIONS: Patients with acquired immunodeficiency syndrome-defining CD4 cell counts undergoing major abdominal surgery developed more complications and had poorer outcomes at 6-month follow-up compared with HIV-infected patients whose CD4 cell counts were greater than 0.20 x 10(9)/L (200 cells/microL). A perioperative septic process and HIV-related pathologic conditions seen at laparotomy are also associated with worse outcomes.     

Influence of respiratory distress syndrome on body composition after preterm birth

AIM: To observe changes in body composition during the first week after birth, in preterm neonates with and without respiratory distress syndrome (RDS), so as to be able to provide optimal fluid and energy intake. METHODS: Twenty four babies with RDS and 19 healthy preterm babies, with gestational ages ranging from 26-36 weeks, were studied daily for the first week after birth. Total body water (TBW) was measured using bioelectrical impedance analysis. The babies were weighed daily and a record made of fluid and energy intake. Body solids were calculated as the difference between body weight and TBW. RESULTS: There was a highly significant reduction in body weight by the end of the week, with the RDS babies losing more than the healthy babies (RDS 7.6%; non-RDS 3.7%). There was no significant difference in the amount of TBW at birth in the babies with and without RDS (RDS 85.1%; non-RDS 85.5%) and both groups lost the same amount of body water (RDS 10.9%; non-RDS 9.9%) by the end of the first week. The amount of total body water lost was unrelated to the volume of fluid administered. There was a loss of body solids during the first day in the RDS group, but, overall, there was a highly significant increase in both groups between birth and day 7, which was greater in the healthy babies (RDS 13.0%; non-RDS 42.7%). CONCLUSIONS: Loss of body water after birth occurs to the same extent in healthy preterm neonates and in babies with RDS and is unrelated to the volume of fluid administered. Given adequate nutritional support, an increase in body solids can accompany early postnatal weight loss and begins almost immediately after birth, in both healthy preterm babies and babies with RDS.     

A simple and rapid determination of the lecithin/sphingomyelin (LS) ratio in amniotic fluids and in pharyngeal aspirates of newborn infants

A simple, rapid method for the routine determination of the lecithin/sphingomyelin (L/S) ratio in amniotic fluid and/or in pharyngeal aspirate of the newborn has been developed. In 33 samples of amniotic fluid at various gestational ages, an L/S ratio corresponding to the fetal age was found: in 16 samples of biochemically immature amniotic fluid (gestation age less than 34 weeks) the mean of the ratio was 1.26 and in 17 samples of mature amniotic fluid (gestation age greater than 35 weeks) the mean value was 3.02. Pharyngeal aspirates of 55 non-selected newborn were examined by the same method. The L/S ratio of 39 infants (gestation age greater than 38 weeks) gave a mean value of 7.3 and that of 16 premature infants (gestation age less than 37 weeks) a mean value of 5.5. In none of these cases did RDS develop after birth. The results suggest that the method is useful for the determination in both amniotic fluid and pharyngeal aspirate.     

Amniotic fluid lecithin/sphingomyelin ratio changes related to centrifugal force

Lecithin/sphingomyelin ratio (L/S ratio) in amniotic fluid has gained wide clinical acceptance as an index of fetal lung maturity. We determined L/S ratios of amniotic fluids centrifuged at various "g-forces." Our studies demonstrate that the L/S ratio value is highly dependent on the g-force used to prepare the fluid. We recommend standardization of the g-force, time, and temperature used in preparation of the amniotic fluid for L/S ratio determination.     

Discontinuation of prophylaxis for Pneumocystis carinii pneumonia in HIV-1-infected patients treated with highly active antiretroviral therapy

BACKGROUND: Prophylactic drugs for Pneumocystis carinii pneumonia (PCP) are strongly recommended for HIV-1-infected patients with CD4 cell counts of less than 200 cells/microL. Because of the highly active antiretroviral therapy (HAART) currently available, we speculated that prophylaxis can be discontinued in patients with CD4 cell counts of more than 200 cells/microL. METHODS: In this prospective observational study, PCP prophylaxis (primary or secondary) was discontinued in HIV-1-infected patients whose CD4 cell count had increased above 200 cells/microL (documented twice with an interval of at least 1 month) as a result of HAART. Patients and their CD4 cell counts were monitored every 3 months. The primary endpoint of the study was the occurrence or reoccurrence of PCP. FINDINGS: 78 patients were enrolled: 62 patients were receiving prophylaxis for primary prevention of PCP and 16 patients for secondary prevention of PCP. At the time of discontinuation of prophylaxis, the mean CD4 cell count was 347 cells/microL, and HIV-1-RNA was not detectable in 61 patients. The lowest mean CD4 cell count during prophylaxis was 79 cells/microL. Patients stopped prophylaxis 9.8 (SD 6.4) months after they started HAART. The mean follow-up after discontinuation of prophylaxis was 12.7 (SD 7.6) months, and none of the patients developed PCP (97.5% one-sided CI 0-4.4%). INTERPRETATION: The preliminary results of this study indicate that PCP prophylaxis can be stopped safely in HIV-1-infected patients whose CD4 cell counts have increased above 200 cells/microL after treatment with HAART.     

Decreased sodium ion absorption across nasal epithelium of very premature infants with respiratory distress syndrome

OBJECTIVE AND STUDY DESIGN: Successful adaptation to air breathing at birth depends on rapid absorption of fetal lung liquid that is mediated by activation of amiloride-sensitive sodium ion channels. To test the relationship between respiratory epithelial Na+ transport and development of respiratory distress syndrome (RDS), we measured nasal transepithelial potential difference (PD) in 31 very premature (< or = 30 weeks of gestation) newborn infants. Infants were retrospectively assigned to RDS (22 infants) and non-RDS (9 infants) groups on the basis of clinical and chest x-ray criteria. RESULTS: Maximal nasal epithelial PD increased with birth weight (-1.2 mV/100 gm) and was lower in infants with RDS (-16.5 +/- 0.6 mV) than in those without RDS (-22.0 +/- 1.3 mV). Infants without RDS had PD values similar to normal fullterm infants. Amiloride inhibition of PD, an index of Na+ absorption, was significantly lower, within the first 24 hours of life, in infants in whom RDS developed (3.8 +/- 0.2 mV; 29.5% +/- 0.8% inhibition) than in those without RDS (6.1 +/- 0.6 mV; 38.6% +/- 0.5% inhibition). Maximal and amiloride-sensitive PD returned to normal during the recovery phase of RDS. CONCLUSIONS: We conclude that Na+ absorption across nasal epithelium increases with increasing birth weight and that impairment of Na+ absorption across the respiratory epithelia of very premature infants may contribute to the pathogenesis of RDS.     

Indirect prediction of fetal lung maturity. Value of ultrasonographic colonic and placental grading

OBJECTIVE: To correlate fetal morphometrics with studies of fetal lung maturity. STUDY DESIGN: One hundred six patients undergoing amniocentesis for fetal lung maturity studies were examined prospectively. Eighty-four patients were normal (79%), and 22 were diabetic (21%). Fetal morphometrics were obtained prior to amniocentesis. The fetal colon and placenta were graded. Discriminant analysis was used to identify variables that were predictive of a mature lecithin/sphingomyelin ratio and the presence of phosphatidylglycerol (PG). All patients delivered within 48 hours of amniocentesis. RESULTS: In the normal group, 28 (33%) fetuses had a grade 3 colon, which was 68% sensitive and 98% specific for a mature amniocentesis. A grade 3 colon was the single best predictor of a mature amniocentesis (P < .001). Twenty-five (29%) fetuses had a grade 3 placenta, which was 64% sensitive and 96% specific for a mature amniocentesis (P < .005). Diabetes did not influence colonic grading since a grade 3 colon was present in seven (32%) patients (47% sensitivity and 100% specificity for PG) (P < .02). Interexaminer and intraexaminer variability for the study was excellent, kappa = 1.0 (P < .001). CONCLUSION: Colonic and placental stage 3 grading are reliable and reproducible ultrasonographic scales that can help predict the findings of fetal lung maturity studies.     

Relationship of CD4 counts to neurophysiological function in HIV-1--infected homosexual men

OBJECTIVE: To explore the relationship of immune dysfunction to neurophysiological measures of brain-stem conduction time. DESIGN: Three-year longitudinal prospective cohort study; results of time 1 analyses reported. SETTING: San Francisco (California) General Hospital, Departments of Psychiatry and Epidemiology. PATIENTS: Volunteer sample of 55 human immunodeficiency virus (HIV)-positive and 37 HIV-negative homosexual men recruited from a larger cohort of homosexual men followed up since 1983 at San Francisco General Hospital as part of an ongoing study of the natural history and course of HIV type 1 infection. INTERVENTION: None. MAIN OUTCOME MEASURES: Auditory brain-stem responses and somatosensory evoked potentials for subjects stratified separately on HIV serostatus, Centers for Disease Control and Prevention symptom groupings, and absolute CD4 counts. RESULTS: The HIV-positive subjects had an increased wave III-V interpeak latency of the right ear auditory brain-stem response compared with the HIV-negative subjects (t test, P < .05). There were no significant differences among the three Centers for Disease Control and Prevention groupings on any evoked potential measure. When HIV-positive subjects were stratified on a measure of immune functioning, ie, CD4 counts, individuals with greater immune suppression were more impaired on speed of auditory brain-stem conduction time (Mann-Whitney U test, P < .05). Furthermore, 85% of subjects impaired on this evoked potential measure had CD4 counts of less than 0.40 x 10(9)/L (400/microL), whereas only 15% of those impaired on this measure had CD4 counts of greater than 0.40 x 10(9)/L. CONCLUSIONS: Asymptomatic HIV-positive subjects who do not have evidence of immune suppression do not appear to be at greater risk for neurophysiological impairment than HIV-negative subjects. The HIV-positive individuals who are immune suppressed (even while asymptomatic) appear to have an increased likelihood of central conduction time slowing as measured by evoked potential procedures.     

Premenstrual dysphoric disorder: controversies surrounding the diagnosis

OBJECTIVE: To evaluate the umbilical and uterine arterial Doppler flow velocity waveform systolic to diastolic (S/D) ratios performed at 24-30 weeks gestation for predicting fetal growth retardation (IUGR). METHODS: A prospective double blind study was conducted in 118 cases of high risk singleton pregnant women. The umbilical and uterine arterial S/D ratios were measured at 24-30 gestational weeks and the pregnancy outcomes were followed up. RESULTS: The prevalence of IUGR in our study population was 16.9%. At 24-30 weeks gestation, the S/D ratio of both umbilical artery and uterine artery in IUGR pregnant women were significantly higher than those in normal pregnant women, while the fetal biometric measurements were normal in all the 118 cases. The sensitivity, specificity and positive predictive value of umbilical arterial S/D ratio to predict IUGR were 80.0%, 83.7% and 50.0% with a Kappa index of 0.51 at 24-30 weeks gestation. With lower sensitivity, specificity, positive predictive value and Kappa index (40.0%, 84.5%, 34.8% and 0.23 respectively), the uterine arterial S/D ratio had less predictive value. CONCLUSIONS: The umbilical arterial Doppler flow velocity waveform S/D ratio may be an earlier predictor for screening of IUGR at 24-30 weeks gestation in high risk pregnant women with normal fetal biometric measurements.     

Transgenic pigs expressing human CD59 and decay-accelerating factor produce an intrinsic barrier to complement-mediated damage

OBJECTIVE: The antenatal and intrapartum management of women with autoimmune thrombocytopenia is controversial. The current approach emphasizes an effort to identify maternal characteristics predictive of severe neonatal thrombocytopenia or to measure fetal platelet counts and perform cesarean section in patients considered to be at risk for neonatal intracranial hemorrhage. In the current study we review our experience with maternal autoimmune thrombocytopenia and neonatal outcome. STUDY DESIGN: Fifty-five pregnancies with autoimmune thrombocytopenia over a 10-year period in three major medical centers in San Diego, California, were evaluated. Maternal characteristics and neonatal outcomes were assessed and compared with those in other recent reports. Data were submitted to Fisher's exact (two-tailed), chi2, and Student t tests, with linear regression performed to analyze the association between variables. RESULTS: Maternal characteristics including platelet count, presence of antiplatelet antibody, antecedent history of autoimmune thrombocytopenia, and corticosteroid therapy were not predictive of severe neonatal thrombocytopenia. Maternal history of splenectomy was significantly correlated with fetal platelet counts <50 x 10(9)/L (odds ratio 5.63; 95% confidence interval 2.2 to 14.3). There were four neonates with severe neonatal thrombocytopenia (8%), and one who was delivered by cesarean section had intracranial hemorrhage. CONCLUSIONS: These findings, combined with others in the literature, confirm that severe neonatal thrombocytopenia is an infrequent complication of maternal autoimmune thrombocytopenia and is not reliably predicted by maternal characteristics. Intracranial hemorrhage is also a rare event and is not related to mode of delivery. Cesarean section should be reserved for obstetric indications only.     

Amniotic fluid tests for fetal lung maturity (author's transl)

Amniotic fluid specimens of 30 pregnant women were examined for the evaluation of the fetal lung maturity. Three assays were used in parallel: the determination of the lecithin concentration, the estimation of the lecithin/sphingomyelin ratio and the shake test. The results were compared together and with the fetal outcome. The shake test has proved to be sufficient for the exclusion of an immature lung. To avoid failure from false-negative results of the shake test an additional determination of the lecithin/sphingomyelin ratio is recommended, whenever clinical dates give rise to expect a mature lung. The determination of the lecithin concentration has no advantage compared to the lecithin/sphingomyelin ratio. Pathology as candida infection or anecephaly falsifies.     

Fetal thrombocytopenia and its relation to maternal thrombocytopenia

BACKGROUND: Neonates with severe thrombocytopenia can have bleeding leading to death or lifelong residual defects. The predictors, frequency, and consequences of fetal thrombocytopenia are not known, nor is it known if there are maternal clinical features that could predict fetal thrombocytopenia. METHODS: We conducted a seven-year cross-sectional study in which platelet counts were determined in newborns' umbilical-cord blood and blood obtained from their mothers at consecutive deliveries in one obstetrical unit. The relations of the umbilical-cord platelet count to maternal risk factors were determined. RESULTS: Platelet counts were determined in blood samples from 15,471 mothers and 15,932 newborn infants. The cord-blood platelet count was less than 50,000 per cubic millimeter in 19 infants (0.12 percent; 95 percent confidence interval, 0.07 to 0.19 percent), whereas the platelet count was less than 150,000 per cubic millimeter in 6.6 percent of the mothers (95 percent confidence interval, 6.2 to 7.0 percent). One infant among those born to 756 mothers with incidental thrombocytopenia, 5 infants among those born to 1414 mothers with hypertension, and 4 infants among those born to 46 mothers with idiopathic thrombocytopenic purpura had cord-blood platelet counts between 20,000 and 50,000 per cubic millimeter. Only 6 infants (0.04 percent; 95 percent confidence interval, 0.01 to 0.08 percent) had cord-blood platelet counts of less than 20,000 per cubic millimeter; all their mothers were among the 18 whose 19 fetuses were at risk for neonatal alloimmune thrombocytopenia. Two of these infants had in utero intracranial hemorrhage. In addition, 3 infants born to these 18 women had cord-blood platelet counts between 20,000 and 50,000 per cubic millimeter; there was 1 stillbirth due to intracranial hemorrhage. CONCLUSIONS: Moderate-to-severe fetal thrombocytopenia is a rare event. The only severely affected neonates with morbidity or mortality due to this condition are those born to mothers with antiplatelet alloantibodies.     

Identification and genetic analysis of Schizosaccharomyces pombe cDNAs that suppress deletion of IRA1 in Saccharomyces cerevisiae

OBJECTIVE: To determine the etiology, pregnancy complications, and outcome of isolated fetal pleural effusion diagnosed antenatally and to evaluate the benefits of prenatal fetal interventions. DATA SOURCES: A literature search of MEDLINE was performed for relevant English language publications between 1985-1991. In addition, reference lists of articles were used to identify reported cases of isolated fetal pleural effusion. METHODS OF STUDY SELECTION: Our search uncovered 31 papers published in peer review journals. From these reports, 82 cases met our selection criteria: All fetuses were diagnosed antenatally with pleural effusion and had no other signs of hydrops at initial diagnosis. DATA EXTRACTION AND SYNTHESIS: The etiology of isolated fetal pleural effusion was unknown in most cases. Possible causes included congenital chylothorax, goiter, lung tumors, and infection. Cardiac defects (4.9%), Down syndrome (4.9%), and polydactyly (1.2%) may be associated with isolated fetal pleural effusion. Perinatal mortality was high (36%) and was related to the development of nonimmune hydrops, prematurity, and pulmonary hypoplasia. Early gestational age at diagnosis of isolated fetal pleural effusion (32 weeks or less) was associated with poor outcome and a neonatal death rate of 55%. In contrast, the neonatal death rate approached 31% as gestational age at diagnosis exceeded 32 weeks. Fifty-four cases were managed conservatively whereas 24 received intrauterine intervention, which included either pleuroamniotic shunt or repeated thoracenteses. Neonatal death rates were 37 and 33%, respectively. CONCLUSION: Not enough data exist to support either the conservative approach or intrauterine pleural drainage in cases of isolated fetal pleural effusion diagnosed antenatally.     

Management of a short femur discovered via ultrasound in utero. Prenatal diagnosis of Stuve-Wiedemann syndrome

BACKGROUND: Malignant mesothelioma reportedly shows different epidemiology and pathology in females, and a proportion are believed to arise spontaneously. METHODS: One hundred and seventy seven cases of malignant mesothelioma in females were reviewed, examined by histochemistry and immunohistochemistry, assessed for asbestosis and lung fibre burden by transmission electron microscopy with energy dispersive x ray analysis, and compared with 31 female controls. RESULTS: Two of one hundred and three cases tested for carcinoembryonic antigen were positive and were excluded from further analysis. Tumour cases showed increased amphibole burdens; in those in whom exposure information was known, 74 (80%) of 93 patients had a history of exposure to asbestos. Seventy two (47%) of 152 patients had lung fibrosis. Tumour site and histological type were little different from those reported in adult males. Mixed type histological pattern, lung fibrosis, and peritoneal site were associated with heavier lung asbestos burdens, but not exclusively. Thirty five (30%) of 117 patients had amphibole burdens of less than 2 x 10(6) fibres/g; the sites affected and the histological pattern of tumours in this group were similar to those in cases with amphibole fibre counts of > or = 2 x 10(6)/g lung. A higher lung amphibole burden than the mean burden in control females was found in 115 (98%) of 117 patients tested. CONCLUSIONS: The pathology of malignant mesothelioma appears to be similar in women and in men, and in cases associated and unassociated with asbestos.