Journal of maternal-fetal investigation : the official journal of French Society of Ultrasound in Medicine and Biology ... [et al.]最新文献

> Objective: To assess the influence of diabetes mellitus on the mechanical wall properties of large maternal and fetal arteries in pregnant women. Methods: Prospective serial monitoring of arterial wall characteristics, using ultrasonic phase-locked tracking of vessel diameters and oscillometric brachial blood pressure measurements. Ten pregnant women with insulin-dependent diabetes mellitus and 15 with gestational diabetes were studied and compared with 20 women in uncomplicated gestation. Results: In women with uncomplicated pregnancy, the stiffness index and the elastic modulus of the maternal aorta were lower (both P < 0.05), whereas the pulse amplitude and the strain were higher (both P < 0.05) in the 12th gestational week than in the 6th week postpartum. These differences did not appear in pregnancy complicated by insulin-dependent diabetes. In early gestation, higher aortic stiffness index and elastic modulus (both P < 0.05) and lower pulse amplitude and strain (both P < 0.05) were recorded in gravidae with insulin-dependent diabetes compared with nondiabetic pregnant women; those with gestational diabetes were not detected in early pregnancy. No intergroup or intragroup differences of stiffness index and pulse amplitude were found in the carotid artery in corresponding gestational ages. In the fetal aorta, the pulse wave velocity increased during the third trimester of normal gestation (P < 0.05) but not in insulin-dependent diabetic pregnancy. Conclusion: The difference found concerning the aortic stiffness between women with insulin-dependent diabetes during pregnancy and those with uncomplicated pregnancy might be interpreted as an altered cardiovascular adaptation to pregnancy in women with diabetes.

> At present preterm delivery is the leading cause of perinatal morbidity and mortality and its incidence is remained stable during the past 10 years. Conventional methods of identifying patients at risk of preterm delivery such as obstetrics history, demographic factors or evaluation of uterine contractions and cervix by digital examination show disappointintly low sensitivity and positive predictive value. In this review we describe new ultrasonographic and biochemical approaches that have been recently proposed to screen for preterm labor both in patients with intact and with premature rupture of the membranes. The ultrasonographic detection of a short uterine cervix and/or of a dilation of the internal os, expression of weakening of the lower uterine segment or cervical ripening, seems to efficiently predict patients at risk of preterm delivery. The efficiency of this marker may be improved by the association with the assay of fetal fibronectin or pro inflammatory cytokines (interleukin-6 and interleukin-8) in cervical secretions. Further by the concentrations of interleukin-6 and interleukin-8 in cervical secretions seems to be possible to predict among patients in preterm labor those secondary to subclinical endoamniotic infection or chorioamnionitis. The use of these new markers in the future may allow a better identification of patients at risk of preterm labor and a proper selection of the treatment (medical or surgical) required for such patients.

> Objective: For more than 20 years, vibroacoustic stimulation testing (VAST) using an artificial larynx has been used worldwide when fetal heart rate monitoring produced patterns with absent or very low variability. In addition to the artificial larynx many other appliances have been used to stimulate a seemingly dormant fetus, but these have rarely been evaluated properly. In this study we tried to evaluate the use of standard mechanical wind-up alarm clocks for VAST. Methods: VAST with an alarm clock was performed successfully in 80 women with normal pregnancies from 36 weeks to term. It was tested by placing the alarm clock on the maternal abdomen just above the fetal head or on the controlateral side of the maternal abdomen to see whether position made any difference and whether coupling with ultrasound gel applied between the alarm clock and the maternal abdomen would affect the degree of fetal reaction to VAST as expressed in heart rate acceleration. Similarly, the effect of the alarm clock VAST on subjective and objective fetal movement patterns as registered by kineto-cardiotocotraphy (K-CTG) in addition to heart rate patterns was investigated. Results: All fetuses showed heart rate acceleration, an increase in heart variability, and increase in movement patterns in the 6 min after the application of alarm clock VAST. No statistically significant difference was found which would favor a particular placement of the alarm clock on the maternal abdomen or the use of ultrasound coupling gel. When K-CTG was performed, patient-perceived fetal movements as expressed with an event marker showed agreement with the machine-registered movements only when patients could see the tracing during registration and no accordance when the K-CTG was turned toward the wall during registation. Conclusion: In keeping with the ALARA principle a conventional wind-up alarm clock appears to be an inexpensive and effective alternative to the electrolarynx.

> Frequent fetal premature ventricular contractions were diagnosed at 39 weeks of gestation. To avoid unnecessary cesarean section, the mother was administered propranolol hydrochloride orally. The tococardiography became feasible and permitted us to evaluate fetal well-being. The patient successfully delivered transvaginally a male infant at 40 weeks of gestation.

> Objective: To investigate the perinatal management and outcome of fetuses diagnosed prenatally with single umbilical artery. Methods: Sixty-one consecutive fetuses with single umbilical artery diagnosed prenatally by ultrasonography were included. Thorough prenatal ultrasonographic screening was carried out to detect associated congenital anomalies. Chromosome study by either amniocentesis or cordocentesis was performed for all 61 of the fetuses with single umbilical artery. Thorough physical examination or autopsy was performed after delivery. Results: All 61 fetuses were confirmed to have single umbilical artery after delivery. Ten (16.4%) of the 61 fetuses with single umbilical artery had abnormal karyotypes. In the single umbilical artery group with abnormal karyotyping, 8 had detectable structural abnormalities, 1 had symmetrical intrauterine growth retardation, and 1 had no apparent congenital anomalies. For the 51 fetuses with normal karyotyping, 28 had abnormal ultrasonographic findings. In 23 fetuses with single umbilical artery without chromosomal or structural anomalies diagnosed in utero, 7 (30.4%) were found to have structural anomalies (3 with congenital heart disease, 3 with congenital renal disease, and 1 with limb deformity) after birth. Conclusion: Prenatal diagnosis of single umbilical artery should be made with caution to avoid false positive cases. When single umbilical artery is diagnosed prenatally, we suggest 1) targeted ultrasonography for detection of anomalies with cardiovascular, genitorenal, and limb-skeletal systems; 2) chromosome study for those with intrauterine growth retardation or other associated defects; and 3) thorough investigation after birth.

> Objective: A nonsubjective evaluation of intrapartum fetal heart rate (FHR) with a neural network (NNW) computer system and its clinical application. Methods: Eight simple FHR data were input into the NNW computer after 16-step normalizations. The computer was composed of 40 units in the input layer, 30 in intermediate layer, and 3 in the output layer, and the probabilities to be normal, suspicious, and pathological were obtained at the output. Before use, the computer was trained 10,000 times by 50-min teacher FHR data of 20 cases with known outcomes. The trained NNW computer was tested by FHRs of another 29 cases. The outcome probabilities in 15 min were calculated every 5 min in another 10 cases, and the bar graphs of the probabilities were displayed in sequence in the trendgrams. Results: The trained NNW computer was 100% accurate in the internal check; in the external check 86% of the results were evaluated correctly with the cardiotocogram, Apgar score, and umbilical arterial pH of the 29 test cases. The FHR scores of our conventional computer FHR analysis were higher in the suspicious and pathological groups than the normal group, and the fetal distress index was high in the pathological group. The trendgrams were simply accurate in typically normal or abnormal cases, transitory abnormal probabilities were shown in intermediate cases, and mixed suspicious and pathological probabilities suggested pathological outcome. Conclusions: The outcome probabilities and their trendgrams in the NNW FHR analysis are promising in objective decision making in the intrapartum stage.

> Objective: To investigate the hemodynamics of uteroplacental circulation in normal and preeclamptic pregnancies using the biomagnetometer SQUID. Methods: Fifteen pregnancies complicated with preeclampsia and 37 normal pregnancies were included in this study. All women were near term. The biomagnetic signals (waveforms) were recorded with the SQUID from the uterine arteries in normal and preeclamptic pregnancies. Using nonlinear analysis we attempted to differentiate these two types of magnetic activity. Results: Applying nonlinear analysis to the biomagnetic activity recorded from the uterine arteries in preeclamptic pregnancies and using dimensionality calculations we observed a clear saturation value for the preeclamptic pregnancies and nonsaturation for the normal pregnancies. These findings were statistically significant and were correlated with fetal heart rate monitoring, pH, and the Apgar score at 1 and 5 min. High amplitude cases were related to normal fetal heart rate patterns, pH > 7.25, and an Apgar score > 7; low amplitude recordings correlated with abnormal fetal heart rate patterns, pH < 7.25, and an Apgar score < 7. Conclusions: It is suggested that biomagnetic measurements with the SQUID in the uterine artery flow and the application of nonlinear analysis are promising procedures in assessing fetal health, especially in high risk pregnancies.

> Spondyloepiphyseal dysplasia is a skeletal disorder in which the vertebrae are flattened, thus making the spine shorter and greatly deformed, with marked thoracic kyphoscoliosis, lumbar lordosis, and a shortened trunk. The pelvis is also severely deformed and contracted. The patient was a 40-year-old nulligravida. At the 33rd week of pregnancy, respiratory distress gradually worsened, and cesarean section under spinal anesthesia had to be done. In women with spondyloepiphyseal dysplasia, uterine expansion is limited. As respiratory difficulties increase, an early delivery may have to be done.

> Objective: A pilot study was designed to investigate whether maternal brachial arterial Doppler shift waveforms analyzed using a Laplace transform analysis technique could distinguish women with gestational hypertension and preeclampsia from women who remained normotensive during their pregnancy. Methods: We examined 50 pregnant women in total. They were divided into two groups. The first was a group of 21 normotensive women, and the second was a group of 29 women with gestational hypertension or preeclampsia, not on medication at the time of study. A Doppler shift waveform of the right and left brachial artery was obtained and analyzed using the conventional parameters of resistance index (RI) and pulsatility index (PI) and Laplace transform analysis. Results: The systolic and diastolic blood pressures and the mean arterial blood pressure at presentation were significantly higher in group 2 as expected. The results of the Laplace transform parameters showed significant differences in the resonant frequency, real pole, c coefficient, and alpha between the two groups. There was no difference in the PI between the two groups, but the differences in RI just reached significance. The Laplace transform parameters in the group with gestational hypertension were consistent with peripheral vasoconstriction, which has been suggested as part of the hemodynamic abnormalities in this condition. Conclusion: Analysis of maternal brachial arterial Doppler shift waveforms by Laplace transform analysis detects differences between normotensive and hypertensive patients. These differences may also reflect some of the hemodynamic changes occurring in gestational hypertension.