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Objective: The purpose of this study was to determine the value of discordant morphometric measurements as identifiers of Down syndrome by evaluating the relationship of biparietal diameter, femur length, biparietal diameter/femur length ratio, and cephalic index between a group of fetuses with trisomy 21 and a control population. Study Design: Biometrie measurements from 48 fetuses with trisomy were reviewed and compared with 107 normal fetuses of similar gestational age. Data were analyzed in 2-week gestational age intervals to determine the effect of gestational age on ultrasonographic detection of Down syndrome. Outcome measures were subject to least-squares linear regression and the t test for analysis. Results: A positive relationship between abnormal morphometric measurements and fetuses with Down syndrome was detected but only during specific weeks of pregnancy. Conclusion: Although it appears that biometric measurements may be useful for Down syndrome, further study is needed before its widespread introduction into clinical practice.

One of the shortcomings of antepartum testing in the post-term pregnancy is that it does not identify the majority of fetuses who develop abnormal intrapartum fetal heart rate changes. The purpose of this study was to determine whether antenatal cardiovascular evaluation could aid in the identification of post-term fetuses at risk for intraparturn heart rate abnormalities. Seventy-five patients with a gestational age greater than 41 weeks underwent a non-stress test, amniotic fluid index and real-time assessment of the heart for the presence or absence of a pericardial effusion. M-mode measurements of the right ventricular inner dimension (RVID), left ventricular inner dimension (LVID), biventricular outer dimension (BVOD) and Doppler velocimetry of the umbilical artery (S/D) were performed. Group I (n = 32) had normal intrapartum heart rate tracings. Group II (n = 20) had abnormal intrapartum fetal heart rate tracings but did not undergo emergency delivery. Group III (n = 23) had abnormal intrapartum fetal heart rate tracings but underwent emergency delivery. When comparing Group I with Group II, the latter had significant differences for abnormal RVID, RVID/LVID ratio, and pericardial effusion. When comparing Groups I and III, there were significant differences for RVID, RVID/LVID ratio, pericardial effusion, BVOD, LVID and amniotic fluid index. Neither the non-stress test nor S/D predicted abnormal intrapartum fetal heart rate patterns. For prediction of abnormal intrapartum heart rate patterns, the sensitivities of the RVID (0.79), LVID (0.33), RVID/LVID ratio (0.72) and BVOD (0.63) were 1.7–4 times greater than the non-stress test (0.19) and the sensitivities of the RVID, RVID/LVID ratio and BVOD were 2 times greater than the amniotic fluid index (0.28). The positive (0.50–0.86) and negative (0.42–0.68) predictive values were similar for all groups. To predict emergency delivery associated with abnormal heart rate tracings, the sensitivities of the RVID (0.83), RVID/LVID ratio (0.70) and BVOD (0.65) were 2.5–3 times greater than the non-stress test (0.26) and 1.5 times greater than the amniotic fluid index (0.39). The positive (0.36–0.56) and negative (0.70–0.86) predictive values were similar. The presence of pericardial effusion had a higher sensitivity than the non-stress test and amniotic fluid index for predicting abnormal intrapartum heart rate patterns but not emergency delivery. Doppler velocimetry of the umbilical artery had a lower sensitivity than the non-stress test and amniotic fluid index for predicting intrapartum heart rate patterns as well as identifying the fetus needing emergency delivery. The results of this study would suggest that there is initially dilatation of the right ventricle which may be associated with abnormal intrapartum fetal heart rate patterns. However, when the left ventricle dilates, leading to cardiomegaly, there is a greater incidence of abnormal intrapartum fetal heart rate changes and associated emergency delivery. The amniotic fluid index appears to be a later finding for predicting abnormal intrapartum fetal heart rate changes. Copyright © 1991 International Society of Ultrasound in Obstetrics and Gynecology

The purpose of this study is to evaluate models for the prediction of birth weight in fetuses suspected of being macrosomic. A total of 141 patients with standard measurements of the head, abdomen, and femur were studied. Linear regressions were performed with single parameters, squares, and all possible cross products in the generation of models with log (birth weight) and birth weight as dependent variables. These models were then compared with a group of previously published equations. Clinically, all models performed poorly. However, two models were significantly less accurate in the prediction of birth weight (p ≤ 0.05). The best results were obtained by equations that used abdominal circumference and femur length measurements. There was no improvement in models that contained log (birth weight) or birth weight as dependent variables or models with complex variables such as squares or cross products of measured parameters. In conclusion, when evaluating patients at risk of macrosomia, the best estimates of fetal weight can be obtained by models that contain abdominal circumference and femur length. (Ann J OBSTET GYNECOL 1990;162:238-42.)

Objective: Our purpose was to evaluate the outcomes of selective termination for fetal anomalies at 8 centers with the largest known experiences worldwide. Study Design: Outcomes in 402 cases of selective termination in pregnancies with dizygotic twins from 8 centers in 4 countries were analyzed by year, gestational age at procedure, and indication. Reductions of fetuses were as follows: 2 to 1, n=345; 3 to 2, 39; ≥4 to 2 or 3, n=18. Potassium chloride was used in all procedures. Results: Selective termination resulted in delivery of a viable infant or infants in >90% of cases. Loss up to 24 weeks occurred in 7.1% of cases in which the final result was a singleton fetus and in 13.0% of cases in which the final result was twins. Loss was 6.6% as a result of structural abnormalities, 7.0% for chromosomal abnormalities, and 10% for mendelian abnormalities (difference not statistically significant). Loss rates for procedures were as follows: 9-12 weeks, 5.4%; 13-18 weeks, 8.7%; 19-24 weeks, 6.8%; and ≥25 weeks, 9.1% (difference not statistically significant). Mean gestational age at delivery was 35.7 weeks. No differences were seen in outcomes by maternal age. The rate of very early premature deliveries has fallen in recent years. There were no known cases of disseminated intravascular coagulation or serious maternal complications. Conclusion: (1) Selective termination, in the most experienced hands, can be technically performed in all 3 trimesters with good outcomes in >90% of cases. (2) The previously observed increase in second- versus first-trimester losses has diminished. (3) Third-trimester procedures, where legal, can be performed with a good outcome for the surviving fetus. (Am J Obstet Gynecol 1999;181:893-7.)

To delineate any possible prognostic indicators, we reviewed the ultrasonographic and nonmorphometric findings in 19 antenatally diagnosed cases of nonimmune hydrops fetalis in which it was chosen to continue the pregnancy. Thirteen fetuses died and six survived. Of all parameters examined, including associated anomalies, abnormal karyotype, location of serous fluid, anemia, and possible cause of nonimmune hydrops fetalis, the most sensitive prognostic indicator was the real-time-directed M-mode echocardiographic measurement of the biventricular outer dimension in diastole. All fetuses with biventricular outer dimensions greater than 95% died, whereas all but one with normal biventricular outer dimensions had resolution of nonimmune hydrops fetalis and survived. This was highly significant (p less than 0.001) with the predictive value of a normal biventricular outer dimension being 86% and the predictive value of an enlarged biventricular outer dimension being 100%.

Our goal was to develop the most comprehensive database possible to counsel patients about selective termination for fetal abnormalities, because no one center has sufficient data to assess much more than crude loss rates.A total of 183 completed cases of selective termination from 9 centers in 4 countries were combined (169 twins, 11 triplets, 3 quadruplets). Variables included indications, methods, (potassium chloride, exsanguination, air embolus), gestational age at procedure, pregnancies lost (or = 24 weeks), gestational age at delivery, and neonatal outcome.Indications for selective termination were 96 chromosomal, 76 structural, and 11 mendelian. Selective termination was technically successful in 100% of cases. In 23 of 183 (12.6%) miscarriage occurred before 24 weeks; 2 of 37 (5.4%) occurred when the procedure done ator = 16 weeks and 21 of 146 (14.4%) when it was done thereafter. Air embolization had a higher loss rate: 10 of 24 (41.7%) compared with 13 of 156 (8.3%) by potassium chloride (chi 2 = 117, p0.0001). Three cases of selective termination performed in monochorionic pregnancies all resulted in pregnancy loss. Among 183 potentially viable deliveries, 7 occurred before 28 weeks, 19 at 29 to 32 weeks, 41 at 33 to 36 weeks, and 93 ator = 37 weeks. Gestational age at delivery was not influenced by the technique used or the indication but was negatively correlated with gestational age at the time of selective termination. No coagulopathy or ischemic damage was observed in survivors. There was no maternal morbidity.(1) Selective termination in experienced hands for a dizygotic abnormal twin is safe and effective when done with potassium chloride. A total of 83.8% of viable deliveries occurred after 33 weeks and only 4.3% at 25 to 28 weeks. (2) Gestational age at the procedure correlated positively with loss rate and inversely with gestational age at delivery; this emphasizes the need for early diagnosis in multifetal pregnancies. (3) Coagulopathy tests are probably unnecessary.

The monocyte monolayer assay (MMA), an in vitro model of in vivo antibody-mediated red blood cell destruction, was previously reported to predict the severity of hemolytic disease of the fetus and newborn accurately when only Rh antibodies and antigen-positive babies were studied. We studied 33 women whose serum contained antibodies with the potential to cause erythroblastosis fetalis; 7 of the 33 women had antibodies other than Rh. None of the babies of the ten women who had consistently negative test results required intrauterine or neonatal transfusions. False-positive MMA results were sometimes found when the fetus was antigen negative. Although the predictive value of a negative MMA was 100%, the efficiency of the MMA was no better than that of the antibody titer. Because of the lack of advantage of the MMA as well as the time and expense it requires, we cannot recommend the general clinical application of this test at this time.

Objective The four-chamber view of the heart is an important component of the ultrasonographic examination of the fetus. However, during the second trimester of pregnancy the fetal heart cannot always be imaged in every patient. The purpose of this study was to ascertain the rate of successful imaging of the fetal heart during the second trimester and to determine factors that may influence imaging. Methods Seven hundred and nine second trimester fetuses were examined and an attempt was made to obtain the four-chamber and outflow tract views of the heart. Analysis included multiple logistic regression models of the main effects and interactions of ten candidate variables. Results The four chambers and outflow tracts were imaged in 643 fetuses (90.7%) and not imaged in 66 (9.3%). Fifty-two of 709 patients (7.3%) had had previous surgery. In the 52 patients with a history of previous surgery, the heart could not be imaged in 18 (34%). Six hundred and fifty-seven patients (92.7%) did not have previous surgery. Of this group, the fetal heart could not be imaged in 48 (7.3%). In only one fetus in which the heart could not be imaged was it because of fetal position. Three independent risk factors that influenced imaging of the fetal heart were gestational age, maternal adipose tissue thickness, and previous lower abdominal surgery. Increasing gestational age increased the probability of imaging the heart, whereas increasing adipose tissue thickness and a history of previous surgery decreased the probability of imaging the heart. Comments When the fetal heart cannot be imaged during the second trimester, these factors should be identified. Using data from this study, the gestational age at which the highest probability of imaging the heart can be determined if the thickness of the adipose tissue and a history of lower abdominal surgery are known.

One of the difficulties for the fetal sonographer is the complete elucidation of structural defects of the cardiovascular system that are associated with intracardiac or great vessel flow disturbances. With the recent introduction of Doppler color flow mapping, in which blood flow is displayed in color superimposed on a real-time image, it has been impossible to identify flow disturbances in the pediatric and adult patient. This study was undertaken to determine whether Doppler color flow mapping could be used in the fetus to identify normal and abnormal cardiovascular anatomy. Thirty-five normal and high-risk fetuses were examined between 16 and 40 weeks of gestation. Doppler color flow mapping identified normal and abnormal anatomy (ventricular septal defect, atrial septal defect, endocardial fibroelastosis, dysplastic pulmonary valve, and tricuspid regurgitation). It appears that Doppler color flow mapping will add a new dimension to fetal cardiovascular imaging.

Identification of squamous cells in the maternal pulmonary arterial circulation, either at autopsy or in blood aspirated from a pulmonary artery catheter, is currently regarded as pathognomonic for amniotic fluid embolism. Sixteen pregnant women underwent pulmonary arterial catheterization for a variety of medical indications. Examination of the buffy coat fraction of the distal lumen aspirate resulted in the identification of squamous cells in all cases. Squamous cells were similarly identified in control specimens from 17 nonpregnant patients; however, the difference in cell count between the pregnant and nonpregnant patients was significant. Such cells presumably reflect, in part, bloodstream contamination from sites of venous access. Reliable differentiation of adult from fetal squamous cells is not possible; however, the significant increase in cell count documented in pregnant patients suggests a possible fetal origin for some squamous cells detected during pregnancy. The detection of squamous cells in the pulmonary arterial circulation of pregnant women is not pathognomonic for amniotic fluid embolism. In a critically ill obstetric patient, such a finding should not deter the clinician from a thorough search for other causes of hemodynamic instability.

The purpose of this study is to assess alterations in vascular resistance as measured by Doppler ultrasound in the postterm fetus. Forty-five postterm patients (greater than or equal to 287 days gestation by "good" dates) underwent Doppler velocimetry and calculation of systolic to diastolic (S/D) ratios of the umbilical, internal carotid, and uterine artery waveforms within 7 days of delivery. Patients were divided into two groups. Group 1 consisted of 26 patients with normal antepartum fetal surveillance that included reactive nonstress test and an amniotic fluid index (using the four-quadrant technique) equal to or greater than 5 cm. Group 2 consisted of 19 patients with antepartum compromise on the antepartum fetal surveillance tests. There was significantly greater (p less than .05) morbidity in group 2 compared to group 1 as judged by cesarean section for fetal distress (47% vs 15%), meconium at delivery (53% vs 4%), and 5-minute Apgar score less than 7 (30% vs 4%). There were no significant differences in the umbilical and uterine artery S/D ratios in the two groups, although patients in group 2 had significantly lower cerebral S/D ratios (3.6 +/- .5) compared to group 1 (4.4 +/- 0.4) (p less than .05). The ratio of cerebral to placental (umbilical) resistance in group 2 was significantly lower (1.1 +/- .3) compared to group 1 (1.8 +/- .3) (p less than .05). There was a low incidence of abnormal umbilical (greater than 3) and uterine (greater than 2.6) S/D ratios in both groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Fetal echocardiography was used to identify a cardiac rhabdomyoma in the second trimester. The combination of this finding with a maternal history of Tuberous Sclerosis allowed the patient and her family to make a more educated decision regarding termination of the pregnancy. Post mortem examination of the fetus confirmed the prenatal findings. This case report demonstrates the importance of ultrasound evaluation of the fetus at risk of recurrence of a genetic syndrome in which one or more anatomical defects might be seen.