Obstetrician & Gynecologist (OB/GYN), Radiologist
21 years of experience
Video profile
Accepting new patients
Brigham & Women's Hospital
75 Francis St
Fenway - Kenmore - Audubon Circle - Longwood, Boston, MA 02115
617-739-0245
Locations and availability (5)

Education ?

Medical School Score
University of Illinois at Chicago (1989)
  • Currently 2 of 4 apples

Affiliations ?

Dr. Shipp is affiliated with 7 hospitals.

Hospital Affilations

Score

Rankings

  • Massachusetts General Hospital
    55 Fruit St, Boston, MA 02114
    • Currently 4 of 4 crosses
    Top 25%
  • Brigham and Women's Hospital
    75 Francis St, Boston, MA 02115
    • Currently 4 of 4 crosses
    Top 25%
  • Metrowest Medical Center
    115 Lincoln St, Framingham, MA 01702
    • Currently 3 of 4 crosses
    Top 50%
  • Mt Auburn Hospital
    330 Mount Auburn St, Cambridge, MA 02138
    • Currently 2 of 4 crosses
  • Quincy Medical Center
    114 Whitwell St, Quincy, MA 02169
    • Currently 1 of 4 crosses
  • Brigham &amp Women`s Hospital
  • Mass General Hospital
  • Publications & Research

    Dr. Shipp has contributed to 62 publications.
    Title Acr Appropriateness Criteria® Acute Pelvic Pain in the Reproductive Age Group.
    Date January 2012
    Journal Ultrasound Quarterly
    Excerpt

    Premenopausal women who present with acute pelvic pain frequently pose a diagnostic dilemma, exhibiting nonspecific signs and symptoms, the most common being nausea, vomiting, and leukocytosis. Diagnostic considerations encompass multiple organ systems, including obstetric, gynecologic, urologic, gastrointestinal, and vascular etiologies. The selection of imaging modality is determined by the clinically suspected differential diagnosis. Thus, a careful evaluation of such a patient should be performed and diagnostic considerations narrowed before a modality is chosen. Transvaginal and transabdominal pelvic sonography is the modality of choice when an obstetric or gynecologic abnormality is suspected, and computed tomography is more useful when gastrointestinal or genitourinary pathology is more likely. Magnetic resonance imaging, when available in the acute setting, is favored over computed tomography for assessing pregnant patients for nongynecologic etiologies because of the lack of ionizing radiation. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every two years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

    Title Acr Appropriateness Criteria(®) on Abnormal Vaginal Bleeding.
    Date December 2011
    Journal Journal of the American College of Radiology : Jacr
    Excerpt

    In evaluating a woman with abnormal vaginal bleeding, imaging cannot replace definitive histologic diagnosis but often plays an important role in screening, characterization of structural abnormalities, and directing appropriate patient care. Transvaginal ultrasound (TVUS) is generally the initial imaging modality of choice, with endometrial thickness a well-established predictor of endometrial disease in postmenopausal women. Endometrial thickness measurements of ≤5 mm and ≤4 mm have been advocated as appropriate upper threshold values to reasonably exclude endometrial carcinoma in postmenopausal women with vaginal bleeding; however, the best upper threshold endometrial thickness in the asymptomatic postmenopausal patient remains a subject of debate. Endometrial thickness in a premenopausal patient is a less reliable indicator of endometrial pathology since this may vary widely depending on the phase of menstrual cycle, and an upper threshold value for normal has not been well-established. Transabdominal ultrasound is generally an adjunct to TVUS and is most helpful when TVUS is not feasible or there is poor visualization of the endometrium. Hysterosonography may also allow for better delineation of both the endometrium and focal abnormalities in the endometrial cavity, leading to hysteroscopically directed biopsy or resection. Color and pulsed Doppler may provide additional characterization of a focal endometrial abnormality by demonstrating vascularity. MRI may also serve as an important problem-solving tool if the endometrium cannot be visualized on TVUS and hysterosonography is not possible, as well as for pretreatment planning of patients with suspected endometrial carcinoma. CT is generally not warranted for the evaluation of patients with abnormal bleeding, and an abnormal endometrium incidentally detected on CT should be further evaluated with TVUS.

    Title The Width of the Uterine Cavity is Narrower in Patients with an Embedded Intrauterine Device (iud) Compared to a Normally Positioned Iud.
    Date January 2011
    Journal Journal of Ultrasound in Medicine : Official Journal of the American Institute of Ultrasound in Medicine
    Excerpt

    The purpose of this study was to determine whether women with intrauterine devices (IUDs) embedded in the myometrium or cervix have a narrower fundal transverse endometrial diameter as seen on 3-dimensional (3D) sonography compared to women whose IUDs are in a normal location.

    Title Tricks for Obtaining a Nuchal Translucency Measurement on the Fetus in a Difficult Position.
    Date January 2011
    Journal Journal of Ultrasound in Medicine : Official Journal of the American Institute of Ultrasound in Medicine
    Title Three-dimensional Ultrasound Detection of Abnormally Located Intrauterine Contraceptive Devices Which Are a Source of Pelvic Pain and Abnormal Bleeding.
    Date August 2010
    Journal Ultrasound in Obstetrics & Gynecology : the Official Journal of the International Society of Ultrasound in Obstetrics and Gynecology
    Excerpt

    To determine whether intrauterine contraceptive devices (IUDs) that are located abnormally within the myometrium or cervix cause a higher incidence of pelvic pain and abnormal bleeding compared with normally positioned devices.

    Title Width of the Normal Uterine Cavity in Premenopausal Women and Effect of Parity.
    Date August 2010
    Journal Obstetrics and Gynecology
    Excerpt

    To estimate the width of the normal uterine cavity at the fundus and evaluate its relationship to parity, gravidity, prior cesarean delivery, uterine volume, and patient age.

    Title Structural Anomalies in Early Embryonic Death: a 3-dimensional Pictorial Essay.
    Date June 2010
    Journal Journal of Ultrasound in Medicine : Official Journal of the American Institute of Ultrasound in Medicine
    Excerpt

    The purpose of this pictorial essay was to determine whether 3-dimensional (3D) surface rendering of a dead first-trimester embryo can provide any information for the loss.

    Title Assessment of the Rate of Uterine Rupture at the First Prenatal Visit: a Preliminary Evaluation.
    Date April 2008
    Journal The Journal of Maternal-fetal & Neonatal Medicine : the Official Journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians
    Excerpt

    OBJECTIVE: To quantify the risk for symptomatic uterine rupture during a trial of labor after prior cesarean delivery based on factors that can be ascertained during early pregnancy. METHODS: From all trials of labor over a 12-year period, we determined those factors associated with an increased or decreased risk for uterine rupture and assigned scores. The following numerical scores were used: 2 points for > or = 2 prior cesarean scars, 1 point for interdelivery interval < or = 18 months, 1 point for maternal age of 30-39 years, 2 points for maternal age > or = 40 years, minus 1 point for women with prior vaginal delivery and one prior cesarean. RESULTS: There were 40 uterine ruptures in 4383 trials of labor (0.91%). Overall, the rate of uterine rupture varied by score: -1-0.26% (1/391), 0-0.25% (4/1613), 1-1.11% (21/1894), 2-2.43% (9/370), 3-3.70% (4/108), and 4-14.29% (1/7), p = .001. CONCLUSIONS: The rate of symptomatic uterine rupture during a trial of labor varies greatly depending on easily identified risk factors, and is low for women without risk factors.

    Title Which Patients Benefit from a 3d Reconstructed Coronal View of the Uterus Added to Standard Routine 2d Pelvic Sonography?
    Date April 2008
    Journal Ajr. American Journal of Roentgenology
    Excerpt

    OBJECTIVE: The objective of our study was to evaluate whether a 3D reconstructed coronal view of the uterus provides added benefit to standard gynecologic sonography. MATERIALS AND METHODS: Sixty-six consecutive patients underwent standard 2D pelvic sonography followed by 3D sonography. The physician determined whether the reconstructed coronal view of the uterus was helpful to make a diagnosis not possible with the 2D scan, helpful to be more confident of a diagnosis suspected on the basis of the 2D scan, or not helpful. Comparison of the demographic information, sonographic findings, and endometrial thickness was made between the patient groups. RESULTS: The 3D coronal views of the uterus added value to the 2D scan in 16 (24%) of the 66 patients. In five of these 16 patients, the coronal view added information about findings not seen using 2D imaging. In the other 11 patients, the diagnostic findings were more confidently seen using the coronal view. The coronal view added no information in 50 patients. The coronal view was helpful in four (12.5%) of 32 patients with an endometrium < 5 mm, one of six patients whose endometrium was incompletely seen with 2D sonography, and 11 (39%) of 28 patients whose endometrium measured > or = 5 mm. The coronal view did not provide benefit in patients who had normal findings on 2D scanning. In three patients referred because of infertility, uterine shape anomalies were diagnosed using the coronal view. CONCLUSION: The 3D coronal view of the uterus is a valuable adjunct to a 2D pelvic scan, particularly in patients presenting with infertility or suspected endometrial lesions. In addition, the coronal view is helpful in patients with an endometrium > or = 5 mm.

    Title What Does Magnetic Resonance Imaging Add to the Prenatal Sonographic Diagnosis of Ventriculomegaly?
    Date January 2008
    Journal Journal of Ultrasound in Medicine : Official Journal of the American Institute of Ultrasound in Medicine
    Excerpt

    OBJECTIVE: The purpose of this study was to determine the contribution of magnetic resonance imaging (MRI) in evaluating fetuses with the sonographic diagnosis of ventriculomegaly (VM). METHODS: Over 4 years, consecutive fetuses with the sonographic diagnosis of VM at 1 facility who underwent prenatal MRI at a second facility were included. The roles of MRI and follow-up sonography were tabulated. The patients were analyzed in 2 groups based on the presence or absence of other central nervous system (CNS) abnormalities. RESULTS: Twenty-six fetuses with a gestational age range of 17 to 37 weeks had sonographically detected VM (atria > or =10-29 mm), including 19 with mild VM (atria 10-12 mm). In group 1, 14 had isolated VM, 6 of which reverted to normal by the third trimester. Magnetic resonance imaging showed cerebellar hypoplasia not shown by sonography in 1 fetus and an additional finding of a mega cisterna magna in a second fetus. In group 2, 12 fetuses had VM and other CNS anomalies on sonography. Additional findings were seen with MRI in 10 of these fetuses, including migrational abnormalities (n = 4), porencephaly (n = 4), and 1 diagnosis each of abnormal myelination, hypoplasia of the corpus callosum, microcephaly, a kinked brain stem, cerebellar hypoplasia, and congenital infarction. There were significantly more fetuses with additional CNS anomalies found by MRI among those in group 2 compared with those in group 1 (Fisher exact test, P = .001). CONCLUSIONS: Although sonography is an accurate diagnostic modality for the evaluation of fetuses with VM, MRI adds important additional information, particularly in fetuses in whom additional findings other than an enlarged ventricle are seen sonographically.

    Title Assessment of the Third-trimester Fetus Using 3-dimensional Volumes: a Pilot Study.
    Date August 2007
    Journal Journal of Clinical Ultrasound : Jcu
    Excerpt

    PURPOSE: To examine whether the third-trimester fetus can be assessed sonographically using 3-dimensional (3D) volume data sets. METHODS: Twenty-seven consecutive third-trimester fetuses were evaluated. Fetuses were scanned using 2-dimensional (2D) imaging followed by 5 3D volume acquisitions. The initial scan was interpreted and reported based on the 2D images. The 3D volume data sets were independently reviewed offline several weeks later by 2 sonologists. Parameters evaluated included fetal presentation, placental location, amniotic fluid volume, fetal biometry including a calculation of estimated fetal weight, and major fetal anatomic structures. The result of the interpretation via 3D reconstruction of the volume from each of the 2 sonologists was compared with the original 2D sonography report. RESULTS: Fetal presentation, amniotic fluid volume, and placental location with respect to the cervix were correctly identified 100% of the time by each sonologist. The estimated fetal weight was within 10% of the 2D estimate 89% (95% CI, 0.71-0.98) of the time for sonologist A and 96% (95% CI, 0.81-0.99) of the time for sonologist B. The majority of major anatomic landmarks were adequately seen by both sonologists. CONCLUSION: Offline review of 3D volume data sets is a reliable method for determining fetal presentation, amniotic fluid volume, placental location, and estimating fetal weight in the third trimester.

    Title Is 3-dimensional Volume Sonography an Effective Alternative Method to the Standard 2-dimensional Technique of Measuring the Nuchal Translucency?
    Date October 2006
    Journal Journal of Clinical Ultrasound : Jcu
    Excerpt

    PURPOSE: To determine whether 3-dimensional (3D) volume scanning is an effective alternative method of measuring nuchal translucency in first-trimester fetuses compared with the standard 2-dimensional (2D) technique, and to report a standardized method of evaluation. METHODS: We measured the nuchal translucency of 29 fetuses between 11.4 and 13.9 weeks of age using the standard 2D sonographic technique with the fetus in a sagittal view. We then rescanned the fetus in a coronal orientation and obtained a 3D volume of the fetal neck area from crown to rump using a consistent technique. The sagittal orientation was reconstructed, and the width of the nuchal translucency was measured electronically using the reconstructed midsagittal view. The measurements using a conventional 2D sagittal view were then compared with the 3D reconstructed sagittal view. The nuchal translucency was adequately measured in all fetuses in which the 3D assessment was attempted. RESULTS: The nuchal translucencies of 29 consecutive fetuses were measured using both 2D and 3D multiplanar reconstruction of the fetal neck. The mean +/- standard deviation for the standard 2D assessment of the nuchal translucency was 1.7 +/- 1.4 mm. Using 3D reconstruction of the Z plane, the measurement was 1.8 +/- 1.6 mm. This was not a statistically significant difference (P = 0.4). There was a very high correlation between the two techniques (r = 0.984, P < 0.001). CONCLUSIONS: There is an excellent correlation between the measurements of the nuchal translucency using standard 2D scanning and those obtained from 3D multiplanar reconstruction of the Z plane. Using a consistent technique, the nuchal translucency can be accurately and reliably measured with a 3D rendering. This technique is potentially useful in fetuses that are not in an optimal position for standard 2D nuchal translucency measurement.

    Title Improving the Efficiency of Gynecologic Sonography with 3-dimensional Volumes: a Pilot Study.
    Date July 2006
    Journal Journal of Ultrasound in Medicine : Official Journal of the American Institute of Ultrasound in Medicine
    Excerpt

    OBJECTIVE: The purpose of this study was to determine whether 3-dimensional (3D) sonography can provide a rapid, efficient, and accurate way to do a transvaginal gynecologic scan compared with traditional 2-dimensional (2D) sonography. METHODS: Thirty-five consecutive patients who underwent gynecologic sonography formed the study cohort. After a standard 2D transvaginal scan was done, including measurements of the endometrium and abnormalities, 4 volume acquisitions were obtained, encompassing the uterus (2 volumes) and the ovaries. These volumes were reviewed offline without any patient information. Endometrium and other measurements were performed on the volumes. The 2D and 3D results were compared by paired t tests. RESULTS: The mean time needed for the standard 2D scan was 2.6 minutes compared with 1.07 minutes for the 3D volume acquisitions. The mean time for the reconstruction, measurement, and interpretation of the volumes offline was 1.19 minutes. The mean time for the entire 3D examination (both parts) was 2.26 minutes (P = .047, comparing 2D with total 3D). There was no significant difference between the measurements of the endometrium, fibroids, and ovarian cysts when comparing 2D and reconstructed 3D images. Two-dimensional and 3D sonography differed little in their ability to identify the organs and the abnormalities on the scans. CONCLUSIONS: This study shows that a complete transvaginal gynecologic examination can be done in 1.07 minutes of scan time and interpreted offline in an additional 1.19 minutes. The 35 cases were scanned and interpreted with the use of 3D sonography in 79.17 minutes total compared with 91.46 minutes of 2D scan time (P = .047). The accuracy of the scan was similar for both techniques.

    Title Three-dimensional Us of the Fetus: Volume Imaging.
    Date April 2006
    Journal Radiology
    Excerpt

    PURPOSE: To retrospectively compare the rapidity, efficiency, and accuracy of three-dimensional (3D) and two-dimensional (2D) ultrasonography (US) for complete anatomic survey in fetuses at 17-21 weeks of gestation. MATERIALS AND METHODS: Institutional review board approval was obtained, informed consent was waived, and the study was HIPAA compliant. Fifty consecutive women undergoing fetal anatomic survey at 17-21 weeks of gestation formed the study cohort. After standard 2D US was performed by one of eight sonographers, the same sonographer also obtained five 3D volumes to encompass the entire fetal anatomy. Three physicians interpreting the scans independently evaluated the completeness of the examination and time needed to read the scans, comparing the standard 2D method with the 3D volume reconstruction technique. The paired t test was used to compare biparietal diameter (BPD), femur length, and performance times between the 3D measurements and the 2D measurement. The t test was used to compare fetal anatomy according to volume angle. Differences were significant when P < .05. RESULTS: Mean time to perform 2D US was 19.6 minutes per examination, whereas mean time to perform complete 3D volume acquisition was 1.8 minutes. Mean times needed to interpret 3D images and measure the BPD and femur were 5.53, 4.79, and 5.34 minutes for the three interpreting physicians. Compared with complete fetal surveys performed with 2D US, individual fetal anatomic landmarks (except for fetal arms and cavum septum pellucidum) were identified more than 94% of the time by using 3D US. Grouping anatomic views by region, the heart, head, extremities, and abdominal views were completely seen in 88%, 90%, 90%, and 95% of patients, respectively. No significant difference was seen between the three physicians regarding completeness of the 3D examinations (P = .7). One fetus had multiple anomalies, with 3D volumes identified as abnormal by all three physicians. Overall, 74% of 3D BPD measurements were within 1 mm of the 2D measurements, and 64% of 3D femur measurements were within 1 mm of the 2D measurements. CONCLUSION: The standard fetal anatomic survey can be performed in less than 2 minutes with 3D volume US, and the volumes can be interpreted in 6-7 minutes, compared with a mean of 19.6 minutes to perform standard 2D US.

    Title How Sonographic Tomography Will Change the Face of Obstetric Sonography: a Pilot Study.
    Date September 2005
    Journal Journal of Ultrasound in Medicine : Official Journal of the American Institute of Ultrasound in Medicine
    Excerpt

    OBJECTIVE: This study was undertaken to determine whether 3-dimensional (3D) volume sonography (sonographic tomography) can yield a far quicker and equally accurate anatomic examination of the second-trimester fetus compared with traditional 2-dimensional (2D) scanning. METHODS: Twenty-five consecutive second-trimester fetuses with normal structural surveys on standard 2D imaging underwent 5 standard 3D volume acquisitions each (in the regions of the head, chest, abdomen, face, and lower extremities) immediately after the 2D scan. The 2D and 3D images were subsequently compared in relation to the completeness of the fetal survey, measurements of the biparietal diameter and femur length, and time required to obtain the fetal survey. RESULTS: The structural surveys were complete in 20 of 25 cases using 3D reconstructed volumes. One fetus had an incomplete evaluation of the face on 3D volumes (and limited on 2D imaging because of the prone position of the fetus). The other 4 fetuses with incomplete surveys done on 3D volumes had missing images of a hand or foot. Three-dimensional reconstructions slightly overmeasured the biparietal diameter compared with the 2D reference standard (mean difference, 1.1 mm; P < .001). For femur length, the mean difference was not statistically significant. It took a mean time of 1.1 minutes to obtain the 3D volumes and 5.5 minutes to reconstruct the complete surveys by the 3D volume method. With the standard 2D technique, the structural surveys were done in a mean time of 13.9 minutes. The mean time difference between both methods was 7.3 minutes (P = 2.4 x 10(-9)). CONCLUSIONS: Using 3D volume acquisition, it is feasible to perform and interpret a structural survey in half the time in which a 2D survey is performed. Further research is necessary to standardize the acquisition of volumes to minimize artifacts and produce uniform images.

    Title Does Ultrasound Have a Role in the Evaluation of Postmenopausal Bleeding and Among Postmenopausal Women with Endometrial Cancer?
    Date May 2005
    Journal Menopause (new York, N.y.)
    Title What Factors Are Associated with Parents' Desire to Know the Sex of Their Unborn Child?
    Date February 2005
    Journal Birth (berkeley, Calif.)
    Excerpt

    BACKGROUND: Parents feel strongly about whether or not to learn the sex of their fetus. We sought to determine which factors are significantly associated with parents' desire to know or not to know the fetal sex during a prenatal ultrasound. METHODS: All women undergoing prenatal ultrasound examinations, except for those with suspected failed pregnancies, were invited to answer a questionnaire at an outpatient referral center for diagnostic ultrasound in obstetrics and gynecology in Boston, Massachusetts. The survey asked about demographic factors, current pregnancy, and past pregnancies, and an open-ended question about whether and why the parents wished to learn, or did not learn, the sex of their fetus. Factors significantly associated with parents' desire to learn the fetal sex prenatally were determined and analyzed. RESULTS: A total of 1,340 questionnaires were completed. Overall, 761/1,302 (58%) of mothers and 747/1,295 (58%) of fathers learned or planned to learn the fetal sex before delivery. Factors most associated with wanting to learn the fetal sex were conceiving accidentally, finding out the sex in a previous pregnancy, not planning to breastfeed, influence of sex on future childbearing plans, planning a move or renovation dependent on sex, and specific parental sex preference. Demographic factors most associated with wanting to learn the fetal sex were father without full-time job, lower household income, unwed mother, maternal age less than 22 or greater than 40 years, no college degree, race other than white, and religion other than Catholic. CONCLUSIONS: Specific demographic and socioeconomic characteristics predicted whether or not parents chose to know the sex of their unborn child. Families in which the pregnancy was unplanned, those in which fetal sex would influence living arrangements or future childbearing plans, and those of lower socioeconomic status wished to know the sex more frequently. Further study is needed to understand parents' motivations underlying the desire to know or not know fetal sex before delivery.

    Title Trial of Labor After Cesarean: So, What Are the Risks?
    Date August 2004
    Journal Clinical Obstetrics and Gynecology
    Title The Making of an Advanced Practice Sonographer.
    Date February 2004
    Journal Journal of Ultrasound in Medicine : Official Journal of the American Institute of Ultrasound in Medicine
    Title Ultrasound Assessment of Ovarian Volume: Does Ovarian Size Matter?
    Date September 2003
    Journal Menopause (new York, N.y.)
    Title Fetal Nose Bone Length: a Marker for Down Syndrome in the Second Trimester.
    Date April 2003
    Journal Journal of Ultrasound in Medicine : Official Journal of the American Institute of Ultrasound in Medicine
    Excerpt

    OBJECTIVE: To evaluate the significance of nasal bone length in relation to the detection of Down syndrome in the second trimester. METHODS: We evaluated consecutive fetuses referred to our facility between 15 and 20 weeks' gestation for sonography and amniocentesis because of an increased risk of aneuploidy. A detailed structural survey, biometric measurements, and measurement of the nasal bone were obtained at the time of amniocentesis and subsequently compared with karyotype. The characteristics of the fetuses with Down syndrome were compared with those of the euploid fetuses. RESULTS: A total of 239 fetuses were evaluated. Sixteen fetuses (7%) had Down syndrome, and 223 were euploid. In fetuses with Down syndrome, 6 (37%) of 16 did not have detectable nose bones, compared with 1 (0.5%) of 223 control fetuses, yielding a likelihood ratio of 83. Detectable nasal bones were seen in 10 fetuses with Down syndrome and 222 euploid fetuses. A receiver operating characteristic curve for the biparietal diameter-nasal bone length ratio showed that a value of 9 or greater detected 100% of fetuses with Down syndrome and 22% of euploid fetuses. If the ratio were 10 or greater, then 81 % fetuses with Down syndrome and 11 % of euploid fetuses would have been identified. If the ratio were 11 or greater, 69% of fetuses with Down syndrome would be identified, compared with 5% of euploid fetuses. CONCLUSIONS: The absence of a nasal bone is a powerful marker for Down syndrome. A short nasal bone is associated with an increased likelihood for fetal Down syndrome in a high-risk population.

    Title Impact of Single- or Double-layer Closure on Uterine Rupture.
    Date March 2003
    Journal American Journal of Obstetrics and Gynecology
    Title The Genetic Sonogram: a Method of Risk Assessment for Down Syndrome in the Second Trimester.
    Date February 2003
    Journal Journal of Ultrasound in Medicine : Official Journal of the American Institute of Ultrasound in Medicine
    Excerpt

    OBJECTIVE: To determine the risk of Down syndrome in fetuses with sonographic markers using the Bayes theorem and likelihood ratios. METHODS: We prospectively evaluated the midtrimester sonographic features of fetuses with Down syndrome and compared them with euploid fetuses. Patients were referred for an increased risk of aneuploidy and evaluated for the presence of structural defects, a nuchal fold, short long bones, pyelectasis, an echogenic intracardiac focus, and hyperechoic bowel. All fetuses underwent amniocentesis at the time of sonographic assessment. The sensitivity, specificity, and likelihood ratios for markers were calculated both as nonisolated and isolated findings. RESULT: There were 164 fetuses with Down syndrome and 656 euploid fetuses. The presence of any marker resulted in sensitivity for the detection of Down syndrome of 80.5% with a false-positive rate of 12.4%. The absence of any markers conferred a likelihood ratio of 0.2, decreasing the risk of Down syndrome by 80%. As an isolated marker, the nuchal fold had an "infinite" likelihood ratio for Down syndrome; a short humerus had a likelihood ratio of 5.8, whereas structural anomalies had a likelihood ratio of 3.3. Other isolated markers had low likelihood ratios because of the higher prevalence in the unaffected population. The likelihood ratios for the presence of 1, 2, and 3 of any of the markers were 1.9, 6.2, and 80, respectively. CONCLUSIONS: Although an isolated marker with a low likelihood ratio may not increase a patient's risk of Down syndrome, the presence of such a marker precludes reducing the risk of aneuploidy. Clusters of markers appear to confer a higher risk.

    Title Post-cesarean Delivery Fever and Uterine Rupture in a Subsequent Trial of Labor.
    Date January 2003
    Journal Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: To evaluate the association of uterine rupture during a trial of labor after cesarean with postpartum fever after the prior cesarean delivery. METHODS: We conducted a nested, case-control study in a cohort of all women undergoing a trial of labor after cesarean over a 12-year period in a single tertiary care institution. The current study was limited to all women undergoing a trial of labor after cesarean at term with a symptomatic uterine rupture and who also had their prior cesarean at the same institution. Four controls, who all had their prior cesarean at the same institution, were matched to each case by year of delivery, number of prior cesareans, prior vaginal delivery, and induction in the index pregnancy. Medical records were reviewed for maximum postpartum temperature for the previous cesarean. Fever was defined as a temperature above 38C. Conditional logistic regression analysis was performed taking into account potential confounding factors. RESULTS: There were 21 cases of uterine rupture included in the analysis. The rate of fever following the prior cesarean was 38% (8/21) among the cases, and 15% (13/84) in the controls, P =.03. Multiple logistic regression analysis examining the association of uterine rupture and postpartum fever adjusting for confounders revealed an odds ratio of 4.0, 95% confidence interval 1.0, 15.5. CONCLUSION: Postpartum fever after cesarean delivery is associated with an increased risk of uterine rupture during a subsequent trial of labor.

    Title Three-dimensional Prenatal Diagnosis of Frontonasal Malformation and Unilateral Cleft Lip/palate.
    Date December 2002
    Journal Ultrasound in Obstetrics & Gynecology : the Official Journal of the International Society of Ultrasound in Obstetrics and Gynecology
    Excerpt

    Frontonasal malformation includes a spectrum of anomalies involving the eyes, nose, lips, forehead and brain. We present a case in which a fetal labial cleft was initially identified using traditional two-dimensional sonography. Three-dimensional sonography with multiplanar reconstruction and surface-rendering were essential to establish the diagnosis of frontonasal malformation with severe nasal hypoplasia and unilateral complete cleft lip/palate.

    Title Second Trimester Ultrasound Screening for Chromosomal Abnormalities.
    Date September 2002
    Journal Prenatal Diagnosis
    Excerpt

    The use of prenatal ultrasound has proven efficacious for the prenatal diagnosis of chromosomal abnormalities. The first sonographic sign of Down syndrome, the thickened nuchal fold, was first described in 1985. Since that time, multiple sonographically-identified markers have been described as associated with Down syndrome. The genetic sonogram, involving a detailed search for sonographic signs of aneuploidy, can be used to both identify fetuses at high risk for aneuploidy and, when normal, can be used to decrease the risk for aneuploidy for a pregnancy when no sonographic markers are identified. Combining the genetic sonogram with maternal serum screening may be the best method of assessing aneuploidy risk for women who desire such an assessment in the second trimester. Trisomy 18, Trisomy 13, and triploidy are typically associated with sonographically identified abnormalities and have a high prenatal detection rate. The use of the described sonographic signs in low-risk women requires further investigation, however, patients at increased risk for aneuploidy due to advanced maternal age or abnormal serum screening can benefit from a genetic sonogram screening for sonographic signs of aneuploidy to adjust their baseline risk of an affected fetus.

    Title The Association of Maternal Age and Symptomatic Uterine Rupture During a Trial of Labor After Prior Cesarean Delivery.
    Date September 2002
    Journal Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: To estimate whether maternal age is associated with a symptomatic uterine rupture during a trial of labor after prior cesarean delivery. METHODS: We retrospectively reviewed the medical records of all patients undergoing a trial of labor after prior cesarean delivery over a 12-year period. We analyzed the labors of women with one prior cesarean and no prior vaginal deliveries. The uterine rupture rate was determined with respect to maternal age. Multiple logistic regression was used to control for potential confounding variables. RESULTS: Overall, 32 (1.1%) uterine ruptures occurred among 3015 women. For women younger than 30 years, the risk of uterine rupture was 0.5%, and for those women aged at least 30 years, the risk of uterine rupture was 1.4% (P =.02). Controlling for birth weight, induction, augmentation, and interdelivery interval, the odds ratio for symptomatic uterine rupture for women aged at least 30 years compared with those less than 30 years was 3.2 (95% confidence interval 1.2, 8.4). CONCLUSION: Women aged 30 years or older have a greater risk of uterine rupture as compared with women younger than 30 years.

    Title Fibroepithelial Bladder Polyp and Renal Tubular Dysgenesis: an Unusual Cause of Third-trimester Oligohydramnios.
    Date January 2002
    Journal Journal of Ultrasound in Medicine : Official Journal of the American Institute of Ultrasound in Medicine
    Title Outcomes of Trial of Labor Following Previous Cesarean Delivery Among Women with Fetuses Weighing >4000 G.
    Date December 2001
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: To compare outcomes at term of a trial of labor in women with previous cesarean delivery who delivered neonates weighing > 4000 g versus women with those weighing < or = 4000 g. STUDY DESIGN: We reviewed medical records for all women undergoing a trial of labor after prior cesarean delivery during a 12-year period. The current analysis was limited to women at term with one prior cesarean and no other deliveries. The rates of cesarean delivery and symptomatic uterine rupture for women with infants weighing > 4000 g were compared to the rates for women with infants weighing < or = 4000 g. Logistic regression was used to control for the potential confounding by use of epidural, maternal age, labor induction, labor augmentation, indication for previous cesarean, type of uterine hysterotomy, year of delivery, receiving public assistance, and maternal race. Adjusted odds ratios and 95% confidence intervals were calculated. RESULTS: Of 2749 women, 13% (365) had infants with birth weights > 4000 g. Cesarean delivery rate associated with birth weights < or = 4000 g was 29% versus 40% for those with birth weights > 4000 g (P = .001). With use of logistic regression, we found that birth weight > 4000 g was associated with a 1.7-fold increase in risk of cesarean delivery (95% CI, 1.3-2.2). The rate of uterine rupture for women with infants weighing < or = 4000 g was 1.0% versus a 1.6% rate for those with infants weighing > 4000 g (P = .24). Although the logistic regression analysis revealed a somewhat higher rate of uterine rupture associated with birth weights of > 4000 g (adjusted OR, 1.6; 95% CI, 0.7-4.1), this difference was not statistically significant. The rate of uterine rupture was 2.4% for women with infants weighing > 4250 g, but this rate did not differ significantly from the rate of uterine rupture associated with birth weights < or = 4250 g (P = .1). CONCLUSION: A trial of labor after previous cesarean delivery may be a reasonable clinical option for pregnant women with suspected birth weights of > 4000 g, given that the rate of uterine rupture associated with these weights does not appear to be substantially increased when compared to lower birth weights. However, some caution may apply when considering a trial of labor in women with infants weighing > 4250 g. In these women with infants weighing > 4000 g, the likelihood of successful vaginal delivery, although lower than for neonates weighing < or = 4000 g, is still 60%.

    Title The Use of Helical Computed Tomography in Pregnancy for the Diagnosis of Acute Appendicitis.
    Date May 2001
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: Accurate diagnosis of acute appendicitis in pregnancy by clinical evaluation is difficult. A safe, reliable test was sought to decrease a delay in diagnosis and to avoid unnecessary invasive procedures. A helical or spiral computed tomographic technique has proven to be a very accurate test in the nonobstetric population for the identification of acute appendicitis. We report its use in pregnant patients with suspected acute appendicitis. STUDY DESIGN: All pregnant patients who were undergoing helical computed tomography at our institution from April 1997 to February 1998 for the suspected clinical diagnosis of acute appendicitis were retrospectively reviewed. Helical computed tomography was performed by standard departmental protocol. A positive study was reported if an enlarged appendix, which did not fill with contrast material, was present with periappendiceal inflammatory changes. Outcomes were determined by the results of surgery and pathologic examination or clinical follow-up. RESULTS: Seven patients were identified in the study period. Two patients had positive findings on helical computed tomography, and acute appendicitis was confirmed at laparotomy and by pathologic inspection. There were no further prenatal complications and both patients delivered at term. Five patients had a normal-appearing appendix on helical computed tomography, and all of these patients had resolution of their pain and symptoms. CONCLUSION: Helical computed tomography appears to be a useful, noninvasive test to accurately diagnose acute appendicitis in pregnancy.

    Title Oxytocin Dose and the Risk of Uterine Rupture in Trial of Labor After Cesarean.
    Date April 2001
    Journal Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: To examine the association between uterine rupture and oxytocin use in trial of labor after cesarean. METHODS: A case-control study was performed. Cases were all women with uterine ruptures who received oxytocin during a trial of labor after a single cesarean delivery within a 12-year period (n = 24). Four controls undergoing trial of labor after a single cesarean delivery were matched to each case by 500 g birth weight category, year of birth, and by induction or augmentation (n = 96). The study had an 80% power to detect a 40% increase in oxytocin duration or a 65% increase in total oxytocin dose. RESULTS: No significant differences were seen in initial oxytocin dose, maximum dose, or time to maximum dose. Although women with uterine ruptures had higher exposure to oxytocin as measured by mean total oxytocin dose (544 mU higher) and oxytocin duration (54 minutes longer), these differences were not statistically significant. Women with uterine rupture who received oxytocin were more likely to have experienced an episode of uterine hyperstimulation (37.5% compared with 20.8%, P =.05). However, the positive predictive value of hyperstimulation for uterine rupture was only 2.8%. CONCLUSION: Although no significant differences in exposure to oxytocin were detected between cases of uterine rupture and controls, the rarity of uterine rupture limited our power to detect small differences in exposure. In women receiving oxytocin, uterine rupture is associated with an increase in uterine hyperstimulation, but the clinical value of hyperstimulation for predicting uterine rupture is limited.

    Title Trial of Labor After 40 Weeks' Gestation in Women with Prior Cesarean.
    Date April 2001
    Journal Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: To compare outcomes in women with prior cesareans delivering at or before 40 weeks' gestation with those delivering after 40 weeks. METHODS: We reviewed labor outcomes over 12 years at one institution for women with one prior cesarean and no other deliveries who had a trial of labor at term. We analyzed the rates of symptomatic uterine rupture and cesarean for term deliveries before or after 40 weeks and stratified for spontaneous and induced labor. Potential confounding by birth weight was controlled using logistic regression. Adjusted odds ratios (OR) and 95% confidence intervals (CI) were calculated. RESULTS: Of 2775 women with one prior scar and no other deliveries, 1504 delivered at or before 40 weeks and 1271 delivered after 40 weeks. For spontaneous labor, rupture rate at or before 40 weeks was 0.5% compared with 1.0% after 40 weeks (P =.2, adjusted OR 2.1, CI 0.7, 5.7). For induced labor, uterine rupture rates were 2.1% at or before 40 weeks and 2.6% after 40 weeks (P =.7, adjusted OR 1.1, CI 0.4, 3.4). For spontaneous labor, rate of cesareans during subsequent trials of labor at or before 40 weeks was 25% compared with 33.5% after 40 weeks (P =.001, adjusted OR 1.5, CI 1.2, 1.8). For induced labor, rate of cesareans during subsequent trials of labor at or before 40 weeks was 33.8% compared with 43% after 40 weeks (P =.03, adjusted OR 1.5, CI 1.1, 2.2). CONCLUSION: The risk of uterine rupture does not increase substantially after 40 weeks but is increased with induction of labor regardless of gestational age. Because spontaneous labor after 40 weeks is associated with a cesarean rate similar to that following induced labor before 40 weeks, awaiting spontaneous labor after 40 weeks does not decrease the likelihood of successful vaginal delivery.

    Title Interdelivery Interval and Risk of Symptomatic Uterine Rupture.
    Date March 2001
    Journal Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: To relate interdelivery interval to risk of uterine rupture during a trial of labor after prior cesarean delivery. METHODS: We reviewed the medical records of all women who had a trial of labor after cesarean delivery over 12 years (July 1984 to June 1996). Analysis was limited to women with only one prior cesarean delivery and no prior vaginal deliveries who delivered term singletons and whose medical records included the month and year of the prior delivery. The time in months between the prior cesarean delivery and the index trial of labor was calculated, and the women were divided accordingly to permit comparison with respect to symptomatic uterine rupture. RESULTS: Two thousand four hundred nine women had trials of labor after one prior cesarean delivery and had complete data from the medical records. There were 29 uterine ruptures (1.2%) in the population. For interdelivery intervals up to 18 months, the uterine rupture rate was 2.25% (seven of 311) compared with 1.05% (22 of 2098) with intervals of 19 months or longer (P =.07). Multiple logistic regression was used to assess the risk of uterine rupture according to interdelivery interval while controlling for maternal age, public assistance, length of labor, gestational age at least 41 weeks, and oxytocin use. Women with interdelivery intervals of up to 18 months were three times as likely (95% confidence interval, 1.2, 7.2) to have symptomatic uterine rupture. CONCLUSION: Interdelivery intervals of up to 18 months were associated with increased risk of symptomatic uterine rupture during a trial of labor after cesarean delivery compared with that for longer interdelivery intervals.

    Title Variation in Fetal Femur Length with Respect to Maternal Race.
    Date March 2001
    Journal Journal of Ultrasound in Medicine : Official Journal of the American Institute of Ultrasound in Medicine
    Excerpt

    We sought to evaluate whether the expected fetal femur length, based on biparietal diameter, varies in second-trimester fetuses with respect to maternal race. The study population was composed of all fetuses scanned from 15 to 20 completed weeks' gestation during a 2-month period (June to August 1998). Maternal race was documented at the time of the ultrasonographic examination. Biparietal diameter and femur length were prospectively documented. The variance from the expected femur length, given the biparietal diameter, was calculated, and the mean variations were compared according to maternal race. The study subgroups were composed of the fetuses of 39 Asian mothers, 31 black mothers, and the first 100 white mothers. The mean values of the variance from the expected fetal femur length by biparietal diameter +/- 1 SD for the various racial groups were as follows: fetuses of Asian mothers, -0.66 +/- 1.64 mm; fetuses of black mothers, 0.88 +/- 1.57 mm; and fetuses of white mothers, 0.13 +/- 1.66 mm (P = .0007). To isolate the differences among the 3 racial groups, the mean values of the variance from the expected femur length by biparietal diameter for the fetuses of Asian and black mothers were compared with the mean value for the fetuses of white mothers (Asian versus white mothers, P = .014; black versus white mothers, P = .026). A significant difference in the mean variance from the expected femur length by biparietal diameter was identified among the fetuses of women in the second trimester with respect to racial group. Less-than-expected femur lengths were noted among the fetuses of Asian mothers, and greater-than-expected femur lengths were noted among the fetuses of black mothers, compared with the femurs of fetuses of white mothers. The implications for the use of fetal femur length as a component of the genetic sonogram in patients of various races require further study.

    Title The Frequency of the Detection of Fetal Echogenic Intracardiac Foci with Respect to Maternal Race.
    Date January 2001
    Journal Ultrasound in Obstetrics & Gynecology : the Official Journal of the International Society of Ultrasound in Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: To determine if there is a racial difference in the frequency of identification of echogenic intracardiac foci (EIF) seen sonographically in the hearts of second-trimester fetuses. METHODS: Over a 2-month period (June 1998-August 1998), all fetuses scanned between 15 and 20 completed weeks' gestation were evaluated prospectively for the presence or absence of EIF. Pregnancies specifically referred for the presence of EIF were excluded. The sonographer performing the scan indicated maternal race as Asian, black, white, or (if maternal race was not clear) unknown. Maternal race, gestational age, and the presence or absence of EIF were prospectively documented. Follow-up of those fetuses with EIF was obtained from the referring physicians' offices. The groups were compared with respect to maternal race and presence or absence of EIF. RESULTS: There were 46, 34, 400, and nine fetuses of the Asian, black, white, and unknown mothers, respectively. The mean gestational age +/- 1 SD at examination was 18.2 +/- 1.6, 17.5 +/- 1.4, 17.7 +/- 1.5, and 17.8 +/- 1.1 weeks, for the Asian, black, white, and unknown mothers, respectively. The incidence of sonographically detected EIF was 30.4, 5.9, 10.5 and 11.1% for the Asian, black, white, and unknown mothers, respectively, P = 0.001. In a multivariate logistic regression model, Asian mothers had an odds ratio of 3.8 (95% CI, 1.8, 7.6) for having a fetus identified as having EIF, as compared with white mothers. CONCLUSIONS: The Asian patient is more likely than patients of other races to have a fetus with identified EIF. The counseling implications for Asian mothers undergoing midtrimester sonography when EIF is identified should be tempered, due to the increased frequency of EIF as a normal finding in the Asian population.

    Title Isolated Polydactyly: Prenatal Diagnosis and Perinatal Outcome.
    Date January 2001
    Journal Prenatal Diagnosis
    Excerpt

    Our objective was to determine the clinical significance of isolated polydactyly identified on prenatal sonogram. All patients with sonographically detected isolated polydactyly scanned over an 11-year period were identified from our database. All patients underwent detailed surveys, and follow-up was obtained by review of the medical records and telephone conversations with parents and referring physicians. Thirteen patients with isolated polydactyly were identified. Follow-up was available in 12 patients. Indications for referral included advanced maternal age (2), second-opinion polydactyly (4), family history of polydactyly (1), uncertain dates (5), and growth (1). The gestational ages at the times of sonographic diagnosis ranged from 17.5 to 34 weeks with all but one case being identified before 23 weeks. Prenatal identification included polydactyly of the upper limb (8), lower limb (4), and both upper and lower limbs (1). Postaxial polydactyly was seen in 12 patients and preaxial in one. Polydactyly was confirmed in all 12 cases in which follow-up was available. Karyotypes were normal in all five fetuses in which amniocentesis was performed. Ten of 12 fetuses were born alive, one died in utero at 34 weeks as a complication of severe pre-eclampsia and one died at term as a result of a cord accident. No surviving neonate had any other identifiable malformation or suspected karyotypic abnormality. In conclusion isolated polydactyly identified by prenatal sonography is associated with good perinatal outcome.

    Title Adenomyosis: Sonographic Findings and Diagnostic Accuracy.
    Date January 2001
    Journal Journal of Ultrasound in Medicine : Official Journal of the American Institute of Ultrasound in Medicine
    Excerpt

    The purposes of this study were to evaluate the accuracy of pelvic sonography in identification of adenomyosis and to characterize the most commonly seen sonographic features. We identified all patients over a 10 year period in whom a prospective diagnosis of adenomyosis was suspected on the basis of sonographic findings and who had undergone hysterectomy at a single hospital. Patients were referred for sonography based on standard indications. Sonographic features used in the diagnosis of adenomyosis consisted of two or more of the following: a mottled inhomogeneous myometrial texture, globular appearing uterus, small cystic spaces within the myometrium, and a "shaggy" indistinct endometrial stripe. Correlation was made with the pathology report on the hysterectomy specimen. Fifty-one women met the study criteria. Forty-three of 51 (84.3%) patients sonographically suspected of having adenomyosis were confirmed as having adenomyosis by pathologic examination. All patients with adenomyosis had a mottled heterogeneous appearing uterus, 95% had a globular uterus, 82% had small myometrial lucent areas, and 82% had an indistinct endometrial stripe. Eight patients (15.6%) who had been suspected of having adenomyosis by pelvic sonography did not have adenomyosis reported in the pathology specimen. Six of these eight (75%) patients had multiple small fibroids, one had stage IV endometriosis, and one had a normal uterine specimen with no evidence of pathology. Pelvic sonography provides an accurate diagnosis of adenomyosis in the majority of cases.

    Title The Prognostic Significance of Hyperextension of the Fetal Head Detected Antenatally with Ultrasound.
    Date December 2000
    Journal Ultrasound in Obstetrics & Gynecology : the Official Journal of the International Society of Ultrasound in Obstetrics and Gynecology
    Excerpt

    OBJECTIVES: The purpose of this study was to evaluate the clinical significance of hyperextension of the fetal head detected by ultrasound prior to the onset of labour. METHODS: Over a 10-year period, we retrospectively identified all fetuses who had hyperextension of the fetal head reported on antenatal ultrasound. Hyperextension referred to persistence of the cervical spine in extreme extension, with an extension angle of at least 150 degrees persisting for the duration of the scan. Follow-up information was obtained from Hospital medical records and obstetrical care providers. RESULTS: Follow-up was obtained on 57 of the 65 fetuses (87.7%) identified over the study period. Ten of the 57 fetuses had normal structural fetal surveys and had sonographically identified resolution prior to delivery. All 10 patients delivered at term and had newborns with normal neonatal courses. Twenty-six of 57 fetuses had no sonographic findings other than persistent hyperextension, and 19 of these 26 fetuses (73%) had normal neonatal courses. Twenty-one of 57 fetuses (37%) had structural anomalies sonographically identified in addition to hyperextension of the fetal head. All 21 of these pregnancies ended in either termination or fetal or neonatal demize. CONCLUSIONS: Although resolution of isolated hyperextension of the fetal head is associated with a normal neonatal outcome, persistent isolated hyperextension of the fetal head can be associated with either a normal or an abnormal neonatal outcome. Fetuses with hyperextended heads and antenatally diagnosed structural anomalies have dismal outcomes. The identification of a fetus with hyperextension of the fetal head should prompt a detailed search for structural abnormalities.

    Title Effect of Previous Vaginal Delivery on the Risk of Uterine Rupture During a Subsequent Trial of Labor.
    Date December 2000
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: We examined the effect of prior vaginal delivery on the risk of uterine rupture in pregnant women undergoing a trial of labor after prior cesarean delivery. STUDY DESIGN: The medical records of all pregnant women with a history of cesarean delivery who attempted a trial of labor during a 12-year period at a single center were reviewed. For the current analysis, the study population was limited to term pregnancies. The effect of previous vaginal delivery on the risk of uterine rupture during a subsequent trial of labor was evaluated. Separate analyses were performed for women with a single previous cesarean delivery and for those with >1 prior cesarean delivery. For each of these subgroups, the rate of uterine rupture among women who had > or =1 prior vaginal delivery was compared with the rate among women with no prior vaginal delivery. Logistic regression analysis was used to examine the associations with control for confounding factors. RESULTS: Of 3783 women with 1 prior scar, 1021 (27.0%) also had > or =1 prior vaginal delivery. During a subsequent trial of labor, the rate of uterine rupture was 1.1% among pregnant women without prior vaginal delivery and 0.2% among pregnant women with prior vaginal delivery (P =.01). Logistic regression analysis controlling for duration of labor, induction, birth weight, maternal age, year of birth, epidural analgesia, and oxytocin augmentation indicated that, among women with a single scar, those with a prior vaginal delivery had a risk of uterine rupture that was one fifth that of women without a previous vaginal delivery (odds ratio, 0.2; 95% confidence interval, 0.04-0.8). In the group of 143 pregnant women with >1 previous cesarean delivery, women with a prior vaginal delivery had a somewhat lower risk of uterine rupture (3.9% vs 2.5%; adjusted odds ratio, 0.6; 95% confidence interval, 0.01-6.7). This difference was not statistically significant. CONCLUSION: Among women with 1 prior cesarean delivery undergoing a subsequent trial of labor, those with a prior vaginal delivery were at substantially lower risk of uterine rupture than women without a previous vaginal delivery.

    Title Prenatal Diagnosis of Oral-facial-digital Syndrome, Type I.
    Date November 2000
    Journal Journal of Ultrasound in Medicine : Official Journal of the American Institute of Ultrasound in Medicine
    Title Labor After Previous Cesarean: Influence of Prior Indication and Parity.
    Date July 2000
    Journal Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: To determine whether the risk of cesarean for women who had trials of labor after one prior cesarean differs from that of nulliparas overall and by indications for those cesareans. METHODS: We reviewed medical records of women who had trials of labor after cesareans between July 1984 and June 1996, and of nulliparas who delivered between December 1994 and August 1995. Cesarean rates for women with prior cesareans were compared with the rates for nulliparas overall and by prior cesarean indication (breech, failure to progress, nonreassuring fetal testing, or other). Lengths of labor for women who had repeat cesareans for failure to progress in index pregnancies were compared by prior cesarean indication. RESULTS: The cesarean rate was 28.7% (634 of 2207) for the prior cesarean group and 13.5% (219 of 1617) for nulliparas (P =.001), and varied according to the prior cesarean indication (13.9%, 37.3%, 25. 4%, and 24.8% for breech, failure to progress, nonreassuring fetal testing, and other, respectively). Mean durations of labor in the index pregnancies for women who had cesareans for failure to progress were 13.9, 11.5, 13.4, and 15.1 hours for breech, failure to progress, nonreassuring fetal testing, and other, respectively. CONCLUSION: Overall rates of cesareans were higher for women with one prior cesarean than for nulliparas. Rates of cesareans after trials of labor were related to the prior cesarean indications. Rates were highest for women whose prior cesareans were for failure to progress and lowest for women whose prior cesareans were for breech. The latter group had a rate that was essentially identical to that of nulliparas. Among women with cesareans for failure to progress in index pregnancies, lengths of labor were shorter for those whose prior cesareans were for failure to progress than for those whose prior cesareans were for other indications, suggesting that physicians may intervene earlier in these cases.

    Title The Sonographic Diagnosis of Dandy-walker and Dandy-walker Variant: Associated Findings and Outcomes.
    Date May 2000
    Journal Prenatal Diagnosis
    Excerpt

    Outcomes of pregnancies with sonographically diagnosed Dandy-Walker (DW) or Dandy-Walker variant (DWV) syndromes vary widely. We examined our own experience with these diagnoses in an effort to identify those sonographic features that best predicted neonatal outcome. We identified 50 fetuses with DW and 49 with DWV diagnosed sonographically. Eighty-six per cent of fetuses with DW and 85% of fetuses with DWV had other sonographically identifiable anomalies, the most common being ventriculomegaly (DW: 32%; DWV: 27%) and cardiac defects (DW:38%; DWV: 41%). Forty-six per cent and 36% of available karyotypes in cases of DW and DWV, respectively, were abnormal. 50 out of 99 women in our series elected pregnancy termination. Only three pregnancies with DW resulted in a living infant, and only one of these had a normal paediatric examination at six-week follow-up. Thirteen out of 49 infants with DWV survived the neonatal period and 7 of 13 were reported initially as normal infants, including six with an isolated finding of DWV. We conclude that overall, the prognosis for these posterior fossa defects is grim but not uniformly fatal. The presence of other anomalies is associated with the worst prognosis. Isolated Dandy-Walker variant has the highest chance of leading to a normal neonate.

    Title Is a Full Bladder Still Necessary for Pelvic Sonography?
    Date May 2000
    Journal Journal of Ultrasound in Medicine : Official Journal of the American Institute of Ultrasound in Medicine
    Excerpt

    The objective was to determine whether a full bladder is routinely necessary for a complete sonographic evaluation of the female pelvis. Over the course of 1 month, all women having a gynecologic sonogram were scanned initially transabdominally through a full bladder by the sonographer (standard images taken). A physician then joined the sonographer and scanned the patient transvaginally without prior knowledge of the findings seen transvesically. The physician finished the examination transabdominally, with the bladder empty. The physician and sonographer then determined (1) whether the scan was sufficient transvaginally only, (2) whether the scan was sufficient transvaginally and transabdominally with an empty bladder, or (3) or whether a full bladder was necessary. Two hundred and six consecutive patients were scanned prospectively. The transvaginal scan alone was sufficient to demonstrate all findings for 172 (83.5%) patients. The transvaginal and transabdominal scans through an empty bladder were needed for 31 (15.1%) patients. Three patients (1.5%) required a full bladder in addition to the other two techniques to visualize one normal ovary each. In conclusion, transvaginal scanning with an adjunctive transabdominal empty bladder approach can replace the full bladder technique for routine pelvic sonography. The transabdominal scan with an empty bladder is necessary, particularly for patients with enlarged uteri. It is no longer reasonable, however, to subject all patients undergoing pelvic sonography to bladder distention.

    Title Amnion-chorion Separation After 17 Weeks' Gestation.
    Date December 1999
    Journal Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: To evaluate the cause of and perinatal outcomes of amnion-chorion separation that is apparent sonographically after 17 weeks' gestation. METHODS: We searched our ultrasound database over 7 years for information on pregnant women who had live fetuses and complete separation between amnion and chorion that persisted beyond 17 weeks' gestation. For inclusion in the study, the women had to have amnion separated from chorion on at least three sides of the gestational sac. Medical records were reviewed for whether women had amniocenteses, results of the amniocenteses, and outcomes of the pregnancies. RESULTS: Of 15 pregnant women with live fetuses, ten had amniocenteses before identification of amnion-chorion separation and five did not. Three had fetuses with Down syndrome, two of whom had amnion-chorion separation evident before amniocentesis, and all three had other sonographic findings suggestive of aneuploidy. Three fetuses died. The other pregnancies were complicated by one or more adverse events, including two fetuses with growth restriction, five preterm deliveries, two with oligohydramnios, and one with abruptio placentae. Five infants were delivered at term and are alive and well. Overall, ten of 15 pregnancies resulted in live newborns, one of whom had Down syndrome. CONCLUSION: Complete amnion-chorion separation that persisted after 17 weeks' gestation is associated with a variety of adverse perinatal outcomes, including aneuploidy.

    Title Intrapartum Uterine Rupture and Dehiscence in Patients with Prior Lower Uterine Segment Vertical and Transverse Incisions.
    Date December 1999
    Journal Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: To determine whether gravidas with prior low vertical uterine incision(s) are at a higher risk for uterine rupture during a trial of labor after cesarean delivery than women with prior low transverse uterine incision(s). METHODS: The medical records of women undergoing a trial of labor after prior cesarean delivery over a 12-year period (July 1984-June 1996) at a tertiary-care hospital were reviewed. Maternal and perinatal outcomes for women with prior low transverse and low vertical incision were compared. Women whose low vertical incision was noted to extend into the corpus of the uterus were excluded. All uterine scar disruptions, which included both symptomatic ruptures and detected asymptomatic dehiscences, were analyzed together, and ruptures were examined separately. RESULTS: The outcomes of 2912 patients undergoing trial of labor for the low transverse group and 377 patients undergoing trial of labor for the low vertical group were compared. Overall, there were 38 (1.3%) scar disruptions in the low transverse group and six (1.6%) in the low vertical group, P = .6. There were 28 (1.0%) symptomatic ruptures in the low transverse group and 3 (0.8%) in the low vertical group, P > .999. The study had a power of 80% to detect an increase in the low vertical rupture rate from 1% (as noted for low transverse incisions) to 3%. CONCLUSION: Gravidas with a prior low vertical uterine incision are not at increased risk for uterine rupture during a trial of labor compared with women with a prior low transverse uterine incision.

    Title Rate of Uterine Rupture During a Trial of Labor in Women with One or Two Prior Cesarean Deliveries.
    Date November 1999
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: We sought to determine whether there is a difference in the rate of symptomatic uterine rupture after a trial of labor in women who have had 1 versus 2 prior cesarean deliveries. STUDY DESIGN: The medical records of all women with a history of either 1 or 2 prior cesarean deliveries who elected to undergo a trial of labor during a 12-year period (July 1984-June 1996) at the Brigham and Women's Hospital were reviewed. Rates of uterine rupture were compared for these 2 groups. Potential confounding variables were controlled by using logistic regression analyses. RESULTS: Women with 1 prior cesarean delivery (n = 3757) had a rate of uterine rupture of 0.8%, whereas women with 2 prior cesarean deliveries (n = 134) had a rate of uterine rupture of 3.7% (P =.001). In a logistic regression analysis that was controlled for maternal age, use of epidural analgesia, oxytocin induction, oxytocin augmentation, the use of prostaglandin E(2) gel, birth weight, gestational age, type of prior hysterotomy, year of trial of labor, and prior vaginal delivery, the odds ratio for uterine rupture in those patients with 2 prior cesarean deliveries was 4.8 (95% confidence interval, 1.8-13. 2) CONCLUSIONS: Women with a history of 2 prior cesarean deliveries have an almost 5-fold greater risk of uterine rupture than those with only 1 prior cesarean delivery.

    Title Uterine Rupture During Induced or Augmented Labor in Gravid Women with One Prior Cesarean Delivery.
    Date November 1999
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: Our purpose was to examine the risk of uterine rupture during induction or augmentation of labor in gravid women with 1 prior cesarean delivery. STUDY DESIGN: The medical records of all gravid women with history of cesarean delivery who attempted a trial of labor during a 12-year period at a single center were reviewed. The current analysis was limited to women at term with 1 prior cesarean delivery and no other deliveries. The rate of uterine rupture in gravid women within that group undergoing induction was compared with that in spontaneously laboring women. The association of oxytocin induction, oxytocin augmentation, and use of prostaglandin E(2) gel with uterine rupture was determined. Logistic regression analysis was used to examine these associations, with control for confounding factors. RESULTS: Of 2774 women in the analysis, 2214 had spontaneous onset of labor and 560 women had labor induced with oxytocin or prostaglandin E(2) gel. The overall rate of rupture among all patients with induction of labor was 2.3%, in comparison with 0.7% among women with spontaneous labor (P =.001). Among 1072 patients receiving oxytocin augmentation, the rate of uterine rupture was 1.0%, in comparison with 0.4% in nonaugmented, spontaneously laboring patients (P =.1). In a logistic regression model with control for birth weight, use of epidural, duration of labor, maternal age, year of delivery, and years since last birth, induction with oxytocin was associated with a 4.6-fold increased risk of uterine rupture compared with no oxytocin use (95% confidence interval, 1.5-14.1). In that model, augmentation with oxytocin was associated with an odds ratio of 2.3 (95% confidence interval, 0.8-7.0), and use of prostaglandin E(2) gel was associated with an odds ratio of 3.2 (95% confidence interval, 0.9-10.9). These differences were not statistically significant. CONCLUSION: Induction of labor with oxytocin is associated with an increased rate of uterine rupture in gravid women with 1 prior uterine scar in comparison with the rate in spontaneously laboring women. Although the rate of uterine rupture was not statistically increased during oxytocin augmentation, use of oxytocin in such cases should proceed with caution.

    Title Does the 10-mhz Transvaginal Transducer Improve the Diagnostic Certainty That an Intrauterine Fluid Collection is a True Gestational Sac?
    Date September 1999
    Journal Journal of Clinical Ultrasound : Jcu
    Excerpt

    PURPOSE: We studied whether a 10-MHz transvaginal transducer improves the diagnostic certainty that a small intrauterine fluid collection is a true gestational sac. METHODS: Over a 6-week period, women who presented with a positive pregnancy test and a fluid collection (devoid of any characteristics such as yolk sac or fetal pole) in the uterus seen with a standard 6-7-MHz transvaginal transducer were entered in the study. The patients were immediately rescanned with a 10-MHz transvaginal probe, and characteristics of the fluid collection using this probe were noted. Specifically, the visualization of a yolk sac or the intradecidual or double decidual sign was considered an objective improvement in the certainty that the fluid collection was a gestational sac. RESULTS: Twelve patients presented with a positive pregnancy test and a fluid collection in the uterus seen with a 6-7-MHz probe. Eight of these fluid collections were smaller than 1 cm in mean diameter, and all 8 of these patients had an objective improvement in the diagnosis of an intrauterine pregnancy using the 10-MHz probe. The other 4 patients had fluid collection 1-2 cm in mean diameter seen at 6-7 MHz. The 10-MHz probe improved the diagnostic confidence in 2 of these 4 patients. CONCLUSIONS: In patients with early pregnancies who have questionable gestational sacs on sonography with standard 6-7-MHz transducers, the 10-MHz probe improves the diagnostic confidence of the presence of an intrauterine gestational sac.

    Title The Second-trimester Fetal Iliac Angle As a Sign of Down's Syndrome.
    Date November 1998
    Journal Ultrasound in Obstetrics & Gynecology : the Official Journal of the International Society of Ultrasound in Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: To determine whether the iliac angle of second-trimester fetuses is a useful sonographic marker for the detection of fetuses with Down's syndrome. METHODS: We prospectively measured the iliac angle for all fetuses karyotyped over a 17-month period. A transverse view of the upper fetal pelvis was obtained at the time of amniocentesis and, by means of a protractor, the angle between the two iliac bones was measured. The angles of all those fetuses with Down's syndrome and the first 500 fetuses with normal karyotypes were compared, as was gestational age and maternal age. RESULTS: Nineteen fetuses with Down's syndrome and 1167 fetuses with normal karyotypes underwent genetic amniocentesis over the study period. The mean gestational age of the fetuses with Down's syndrome was 16.6 weeks (+/- 1.9 weeks), and for the controls, 16.1 weeks (+/- 1.4 weeks) (p = 0.3). The mean maternal ages were 34.7 years (+/- 4.8 years) and 35.4 years (+/- 4.1 years) for those pregnancies with Down's syndrome and with normal karyotypes, respectively (p = 0.5). The mean iliac angle was 80.1 degrees (+/- 19.7 degrees) for those fetuses with Down's syndrome, and 63.1 degrees (+/- 20.3 degrees) for those fetuses with normal karyotypes (p = 0.0004). The iliac angle was at least 90 degrees in 36.8% (seven of 19 fetuses) with Down's syndrome and in 12.8% (64 of 500 fetuses) with normal karyotypes (p = 0.003). CONCLUSION: Fetuses with Down's syndrome have a significantly larger iliac angle than fetuses with normal karyotypes. Use of an iliac angle cut-off point of 90 degrees would identify over one-third of second-trimester fetuses with Down's syndrome. However, because of the high false-positive rate (12.8%), the iliac angle is not useful in a high-risk population as a screening test when used in isolation.

    Title Trial of Labor After Cesarean Delivery: the Effect of Previous Vaginal Delivery.
    Date November 1998
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: This study examined the effects of order of previous modes of delivery on the rate of cesarean delivery and duration of a trial of labor among women with a history of 1 previous cesarean delivery and 1 previous vaginal delivery. STUDY DESIGN: The medical records of 4393 women at our institution who were seen June 1984-July 1996 for a trial of labor after a previous cesarean delivery were abstracted. The 800 women with a history of 1 previous cesarean and 1 previous vaginal delivery were included in this analysis. They were split into 2 groups by obstetric history: (1) 1 cesarean delivery followed by 1 vaginal delivery (vaginal last) and (2) 1 vaginal delivery followed by 1 cesarean delivery (cesarean last). Patient characteristics, durations of labor, and rates of cesarean delivery were compared with chi2 analysis, the Student t test, and the Wilcoxon rank sum test. Possible confounding variables were controlled for with multivariate logistic regression. RESULTS: The rates of cesarean delivery for the vaginal last and cesarean last groups were 7.2% and 14.7%, respectively (P = .002). The median durations of labor for the vaginal last and cesarean last groups were 5.6 and 7.0 hours, respectively (P = .01). The differences in cesarean rates and durations of labor were seen regardless of the indication for the previous cesarean delivery. CONCLUSIONS: Among women with 1 previous cesarean and 1 previous vaginal delivery, those whose most recent delivery was vaginal had a lower rate of cesarean delivery and shorter duration of labor than did those whose most recent delivery was cesarean.

    Title The Significance of Prenatally Identified Isolated Clubfoot: is Amniocentesis Indicated?
    Date April 1998
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: Our purpose was to determine the significance of finding an isolated clubfoot on a prenatal sonogram. STUDY DESIGN: All fetuses found to have an isolated congenital clubfoot over a 9-year period were retrospectively identified. Fetuses with associated anomalies were excluded. Review of medical records for obstetric and neonatal outcome and pathologic and cytogenic results were tabulated. RESULTS: Eighty-seven fetuses were identified from our database as having isolated clubfoot on prenatal ultrasonography, with complete follow-up available for 68 fetuses. Sixty of the 68 fetuses were confirmed as having clubfoot after delivery (false-positive rate = 11.8%). The male/female ratio was 2:1. Four fetuses (5.9%) had abnormal karyotypes: 47,XXY, 47,XXX, trisomy 18, and trisomy 21. Nine fetuses had hip or other limb abnormalities noted after birth. Other anomalies not detected until delivery included a unilateral undescended testis, ventriculoseptal defects (n = 2), hypospadias (n = 2), early renal dysplasia, mild posterior urethral valves, and a two-vessel cord. Five of the 68 patients (including those with aneuploidy) had pregnancy terminations. Eleven patients were delivered preterm. CONCLUSION: Karyotypic evaluation is recommended when isolated clubfoot is identified on prenatal sonogram because other subtle associated malformations may not be detected ultrasonographically in the early second trimester.

    Title Significance of an Echogenic Intracardiac Focus in Fetuses at High and Low Risk for Aneuploidy.
    Date March 1998
    Journal Journal of Ultrasound in Medicine : Official Journal of the American Institute of Ultrasound in Medicine
    Excerpt

    Our objective was to evaluate the significance of an echogenic intracardiac focus in a mixed population of fetuses at high and low risk for aneuploidy. Over a 1 year period, we prospectively identified all fetuses with an echogenic intracardiac focus seen during prenatal sonography. A detailed structural evaluation was performed on each fetus as permitted by gestational age. The location and number of foci were tabulated prospectively, as were associated abnormalities. Follow-up was obtained by review of the medical record. Of the 290 fetuses who had an echogenic intracardiac focus, 14 of them were aneuploid (4.8%). Of the 290 mothers, 125 women were aged 35 years or older and 165 women were younger than 35 years old. Among the 125 fetuses born to women 35 years or older, eight were aneuploid fetuses (6.4%), while among the 165 fetuses of younger mothers, six were aneuploid fetuses (3.6%) (rate ratio = 1.8; 95% confidence interval [extremes] = 0.6, 4.9). Only one of the 14 aneuploid fetuses had an echogenic intracardiac focus as the only sonographic finding, and this occurred in a woman aged 41 years. The majority of the echogenic intracardiac foci (87.6%) were located in the left ventricle, while 4.8% of the foci were right-sided and 7.6% were bilateral. Among the 14 aneuploid fetuses, 14% had bilateral echogenic intracardiac foci and 7% had right-sided foci. Among the euploid fetuses, 7.3% had bilateral echogenic intracardiac foci and 4.7% had right-sided foci. In conclusion, we have shown that the presence of an echogenic intracardiac focus does raise the risk that the fetus has a chromosomal abnormality, most commonly Down syndrome, although all but one aneuploid fetus in our study had other sonographic findings.

    Title The Association of Early-onset Fetal Growth Restriction, Elevated Maternal Serum Alpha-fetoprotein, and the Development of Severe Pre-eclampsia.
    Date July 1997
    Journal Prenatal Diagnosis
    Excerpt

    From Antenatal Diagnostic Center referrals over 22 months, consultations for early-onset fetal growth restriction versus skeletal dysplasia were retrospectively identified. Those with elevated maternal serum alpha-fetoprotein (MSAFP) levels are the focus of this report. All had an early ultrasound confirming menstrual dates and subsequent sonography at < 28 weeks with at least two fetal biometric measures delayed by > or = 2 standard deviations from mean values. Of the five patients identified, the mean gestational age at the time of diagnosis of fetal growth restriction was 23.3 +/- 2.9 weeks. All had normal karyotypes and normal amniotic fluid AFP. None of the patients had evidence of hypertension or pre-eclampsia at diagnosis of fetal growth restriction. All five gravidas subsequently developed severe pre-eclampsia from 5.5 to 12.5 weeks after documentation of fetal growth delay. Three developed HELLP syndrome. Pregnancies were continued a mean duration of 10-2 weeks, with all five delivering at preterm gestations (mean = 33.5 +/- 1.7 weeks) for maternal indications of severe pre-eclampsia. Unexplained early-onset fetal growth restriction in conjunction with unexplained elevations of MSAFP together consistently heralded the subsequent development of severe pre-eclampsia.

    Title The Iliac Angle As a Sonographic Marker for Down Syndrome in Second-trimester Fetuses.
    Date March 1997
    Journal Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: To determine whether measurements of the iliac wing angle on sonograms of the second-trimester fetus can be used to detect fetuses at increased risk for Down syndrome. METHODS: All second-trimester Down syndrome fetuses karyotyped by amniocentesis over 5 years for whom adequate views of the iliac bones were available were reviewed retrospectively. The control group consisted of consecutive, normal second-trimester fetuses undergoing karyotyping during the same period. The angles between the iliac bones of the fetal pelves were measured on transverse sonograms, and the two groups were compared. A separate prospective evaluation of the ideal level for measurement of the iliac angle was made in two fetuses, one with and one without Down syndrome. RESULTS: We evaluated 38 Down syndrome and 46 control fetuses. The mean iliac-angle measurements differed significantly for the Down syndrome fetuses as compared with normal control fetuses: 78.8 degrees +/- standard deviation (SD) 18.5 and 66.9 degrees +/- SD 13.9, respectively. An iliac angle of at least 90 degrees was measured in 14 (36.8%) Down syndrome fetuses and in two (4.3%) control fetuses, also a significant difference. In a prospective pilot evaluation of two fetuses, we measured the largest iliac angle at the most cephalad level of the iliac bones, and the smallest angle was measured at the most caudad level. The iliac angle measurements for the fetus with Down syndrome ranged from 55 degrees to 100 degrees; for the normal fetus, the range was 52 degrees to 80 degrees. CONCLUSION: Although there is considerable overlap, the average iliac angle for fetuses with Down syndrome is significantly larger than that of normal fetuses. The angle measurement varies widely in any given fetus and is dependent on the level of the image. A prospective study is needed to evaluate the best level of angle measurement for the detection of fetuses with Down syndrome.

    Title Fetal Origin of Amniotic Fluid Polymorphonuclear Leukocytes.
    Date March 1997
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: Although polymorphonuclear leukocytes are the inflammatory cells most frequently recovered from the amniotic cavity in cases of suspected intrauterine infection, the source of these cells has not been definitively determined. We took advantage of the gender difference between the mother and her male fetus, and we report four cases in which amniotic fluid polymorphonuclear leukocytes were identified as fetal by fluorescence in situ hybridization with probes specific for X and Y chromosomes. Fetal membranes were intact at the time amniotic fluid was obtained in all cases. STUDY DESIGN: Amniotic fluid was obtained from women with male fetuses in premature labor with clinical or laboratory evidence of infection. Cytospin preparations of amniotic fluid samples with polymorphonuclear leukocytes were prepared and sequentially stained with fluorescent reagents. To determine which cells were polymorphonuclear leukocytes, all replicate samples were stained with the fluorescent nuclear stain 4'-6-diamidino-2-phenyl-indole. This allowed definition of the characteristic multilobed polymorphonuclear leukocytes nuclear morphologic features. The sample was then probed with a rhodamine-labeled probe specific for the X chromosome and a fluorescein-labeled probe specific for the Y chromosome to assess whether the polymorphonuclear leukocytes were male or female. RESULTS: Ninety percent to 99% of polymorphonuclear leukocytes identified by normal multiple lobed nuclear morphologic study on 4'-6-diamidino-2-phenyl-indole staining had an X and Y chromosome and were therefore fetal cells. CONCLUSIONS: These data demonstrate a fetal response during intraamniotic infection. Further investigation of the roles for maternal and fetal polymorphonuclear leukocytes in chorioamnionitis may provide valuable information about the critical interaction of the two immune responses in this setting.

    Title Outcome of Singleton Pregnancies with Severe Oligohydramnios in the Second and Third Trimesters.
    Date December 1996
    Journal Ultrasound in Obstetrics & Gynecology : the Official Journal of the International Society of Ultrasound in Obstetrics and Gynecology
    Excerpt

    We evaluated the significance of severe oligohydramnios, or anhydramnios, in the second and third trimesters, by determining the range of etiologies as well as the differences in fetal and neonatal outcome. All prenatal ultrasound results on pregnancies found to have severe oligohydramnios over a 7.5-year period at 13-42 weeks' gestation were retrospectively collected. Follow-up results were obtained from review of medical records, autopsies and pathology reports. A total of 250 singleton pregnancies met the criteria of having severe oligohydramnios. A bimodal distribution in gestational age at diagnosis was seen, with more cases diagnosed at 13-21 weeks and at 34-42 weeks. Fetal abnormalities were present in 50.7% of those diagnosed with severe oligohydramnios in the second trimester and in 22.1% of those in the third trimester. There were 10.2% and 85.3% survivors when severe oligohydramnios was diagnosed in the second and third trimesters, respectively. The rate of aneuploidy was at least 4.4% for the entire singleton population. A bimodal distribution of pregnancies presenting with severe oligohydramnios represents two different naturally occurring populations in terms of both etiology and prognosis.

    Title A Case of Fetal Decapitation.
    Date November 1996
    Journal Journal of Ultrasound in Medicine : Official Journal of the American Institute of Ultrasound in Medicine
    Title Prenatal Diagnosis of a Grade Iv Sacrococcygeal Teratoma.
    Date June 1996
    Journal Journal of Ultrasound in Medicine : Official Journal of the American Institute of Ultrasound in Medicine
    Title The Ultrasonographic Appearance and Outcome for Fetuses with Masses Distorting the Fetal Face.
    Date January 1996
    Journal Journal of Ultrasound in Medicine : Official Journal of the American Institute of Ultrasound in Medicine
    Excerpt

    Our objective was to determine the appearance, cause, and outcome of fetal face masses diagnosed antenatally by ultrasonography. Over a 6 year period, 10 consecutive fetuses with facial masses were identified. Ultrasonographic findings, neonatal pathologic findings, and outcome data were correlated. Four (40%) of the 10 fetuses died, including one with a palatal teratoma associated with a Dandy-Walker malformation and three with intracranial teratomas--one of which was associated with hydrops fetalis. Among the survivors, one fetus had a dacryocystocele that was managed conservatively and one had drainage of a salivary gland cyst. The remaining four neonates had successful excision of their tumors in the neonatal period and survived; these infants had a nasal teratoma, a thyroid teratoma, a gingival granular cell tumor, and a scalp hemangioma. Four of the 10 pregnancies had associated polyhydramnios, three of which ended in stillbirth or neonatal death. In conclusion, 40% of the fetuses with antenatal diagnosis of fetal facial masses did not survive. If those with intracranial teratomas are removed from this group, one of seven (14%) fetuses with extracranial masses died. The intracranial teratomas were uniformly fatal. Polyhydramnios was associated with poor outcome.

    Title Scrotal Inguinal Hernia in a Fetus: Sonographic Diagnosis.
    Date December 1995
    Journal Ajr. American Journal of Roentgenology
    Title Sonographically Detected Abnormalities of the Umbilical Cord.
    Date July 1995
    Journal International Journal of Gynaecology and Obstetrics: the Official Organ of the International Federation of Gynaecology and Obstetrics
    Excerpt

    OBJECTIVES: This study was undertaken as a retrospective chart review to evaluate the range of umbilical cord abnormalities detected by prenatal sonography, as well as the outcome and pathologic correlation. METHODS: We identified 13 cases of umbilical cord abnormalities detected sonographically over a 46-month period. We evaluated the ultrasound appearance, size, location, and color Doppler characteristic in each case. RESULTS: There were 4 instances of clear cysts on the umbilical cord, 8 with complex masses, and 1 with complete, cystic encasement of the cord throughout its length. The pathology included vascular abnormalities (hemangioma, hematoma, varicosity), edema of the umbilical cord with pseudocysts, and syncytial knots. There was 1 known karyotypic abnormality (trisomy 13). Twelve of the 13 newborns survived; the neonatal death occurred in the fetus with trisomy 13. CONCLUSION: The presence of umbilical cord abnormalities may represent a variety of pathologic entities. Clinical outcome is usually favorable.

    Title Levorotation of the Fetal Cardiac Axis: a Clue for the Presence of Congenital Heart Disease.
    Date January 1995
    Journal Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: To evaluate the use of the cardiac axis within the chest for the prenatal detection of congenital heart defects. METHODS: We reviewed retrospectively the sonographic findings of all fetuses scanned between 17 and 40 weeks' gestation and diagnosed prenatally as having heart defects. The cardiac diagnoses were confirmed postnatally. The control group consisted of 75 consecutive fetuses with normal fetal surveys and newborn follow-up examinations. The cardiac axes were measured retrospectively using an image of the four-chamber view of the heart and measuring the angle between the interventricular septum and a line bisecting the chest. Mean and standard deviations (SDs) of the axis measurements in normal and abnormal fetuses were compared by Student t test. RESULTS: The 75 fetuses with heart defects diagnosed by prenatal sonogram had a mean cardiac axis of 56 +/- 13 degrees, compared with 43 +/- 7 degrees in normal fetuses (P < .001). Using 57 degrees (two SDs above the mean for normal fetuses) as the upper limit of normal, 33 of 75 (44%) abnormal fetuses versus none of 75 normal fetuses were identified. The frequency of cardiac rotation was greater in fetuses with truncus arteriosus, Ebstein's anomaly, pulmonic stenosis, coarctation of the aorta, and tetralogy of Fallot. CONCLUSION: The presence of a cardiac axis exceeding 57 degrees in the fetal chest is associated with a substantial risk of congenital heart defects. The finding of an abnormal axis should prompt further evaluation of the fetal heart.

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