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PubMed2004

Fetal endoscopic surgery: indications and anaesthetic management.

Fetal intervention for certain life-threatening conditions has progressed from being primarily experimental in nature to the standard of care in certain circumstances. While surgical techniques have advanced over the past few years, the anaesthetic goals for these interventions have remained the same; namely, minimizing maternal and fetal risk as well as maximizing the chances of a successful fetal intervention and optimize the conditions necessary to carry the fetus to term gestation. Fetal endoscopic techniques allow access to the fetus without the need for a hysterotomy incision, thus improving the chances of controlled post-operative tocolysis and term gestation after fetal intervention. This procedure, however, is not without associated risks to both fetus and mother. This chapter will address the fetal diseases that may benefit from fetoscopic intervention, the rationale behind why maternal and fetal anaesthesia is required, the various anaesthetics used for these cases and specific considerations of both maternal and fetal physiology that aid in the determination of the best anaesthetic technique for individual cases. Methods of intra-operative fetal monitoring and fetal resuscitation will also be discussed.

Analgesia↗
PubMed1997

Neonatal outcomes of teenage pregnancy in a military population.

OBJECTIVE: To compare the use of prenatal care, incidence of pregnancy complications, and neonatal outcomes among adolescent mothers with those among older mothers in a military population with equal access to a tertiary care center. METHODS: We reviewed the neonatal data base of a military tertiary care center for the period 1990-1996. All singleton births at least 20 weeks' estimated gestational age (EGA) or with birth weight at least 500 g were included. Maternal transfers were excluded. Mothers were divided into five age groups, with the ranges 13-17, 18-19, 20-24, 25-29, and 30 or more years. Prenatal care was assessed by the Kessner index. Data were analyzed by chi 2 test, t test, Mann-Whitney U test, and logistic regression techniques. RESULTS: Included in the study were 10,168 infants (344 aged 13-17, 893 aged 18-19, 3244 aged 20-24, 3095 aged 25-29, and 2592 aged 30 or more years). There was a greater percentage of Hispanic mothers among adolescents aged 13-17 years (48.3%); this percentage decreased as maternal age increased (32.7% to 14.6%). The percentage of white mothers was greatest for mothers over 30 years old (72.1%), and this percentage decreased as maternal age decreased (70.3% to 35.8%). The percentage of black mothers remained relatively constant in all age groups (12.2-16.0%). There were significant differences in sponsor's rank distribution among groups; mothers 25-29 years old and over 30 years old had higher-paying ranks whereas both teenage groups were of predominantly lower-paying ranks. Gestational age at the first prenatal visit and overall use of prenatal care were significantly improved as maternal age increased for each successive age group. Older mothers had significantly higher rates for diabetes and abnormal fetal sonograms than younger mothers; younger mothers had increased rates for sexually transmitted disease, fetal growth restriction, and tobacco use. Multivariate analysis demonstrated that fetal complications, adequate prenatal care, black maternal race, and lower rank were significant independent risk factors for high-risk outcomes. Young maternal age was not an independent risk factor for prematurity or low birth weight. CONCLUSION: Although adolescent mothers (13-17 years old) used prenatal care less than older mothers, there were no differences in the incidence of prematurity, low birth weight (LBW), or neonatal survival among this group of women cared for in a military tertiary health care setting. In this health care setting, risk for premature birth and LBW are related to complications of pregnancy, maternal race, and lower-paying rank.

Adolescent↗
PubMed1986

Percutaneous umbilical blood sampling in the management of Kell isoimmunization.

As the use of Rhesus immune globulin has decreased the incidence of Rh sensitization, other red blood cell antigen systems have become relatively more common. The most common of these is the Kell antigen, which often produces unexpectedly severe fetal disease. High-resolution ultrasound was used to guide in the sampling of fetal blood directly from the umbilical cord as an aid in the management of these patients.

Adult↗
PubMed1997

Diagnosis and management of early non-immune hydrops fetalis.

Fetal hydrops is a common symptom of fetal disease at any stage of gestation. The aetiological mechanisms leading to non-immune fetal hydrops are complex and their impact variable at different stages of gestation. In early pregnancy, primary or secondary intra-uterine cardiac failures due to major cardiovascular defects are more often linked to a chromosomal abnormality than during the second half of gestation. In these cases, an increase of the nuchal translucency thickness is probably the first stage of fetal hydrops. Depending on the severity of the underlying defect, the next stage is generalized skin oedema with eventual placental oedema, ascites and pleural effusion. The natural history of fetal hydrops remains poorly understood and thus the prognostic factors determining fetal outcome are still unknown. Examination of the fetal nuchal anatomy between 10 and 15 weeks of gestation and the follow-up of these pregnancies offer an opportunity for an early screening in most aneuploidies and cardiovascular defects, and a better understanding of the aetiopathology of fetal hydrops.

Chromosome Aberrations↗
PubMed2005

Targeting the respiratory muscles of fetal sheep for prenatal gene therapy for Duchenne muscular dystrophy.

OBJECTIVE: Duchenne muscular dystrophy (DMD) is a lethal degenerative muscular disease. Fetal gene therapy may correct the primary genetic defect. Our aim was to achieve expression of a reporter gene in the respiratory muscles of early gestation fetal sheep. STUDY DESIGN: An adenovirus vector containing the beta-galactosidase reporter gene (AdRSVbetagal) was injected into the thoracic musculature (n = 3) and pleural cavity (n = 6) of fetal sheep (61-67 days' gestation) under ultrasound guidance. Tissues were harvested after 48 hours and site and intensity of beta-galactosidase expression were assessed. RESULTS: Limited transgene expression observed after a single injection was improved by multiple injections, but remained localized. Ultrasound-guided creation of a hydrothorax led to an increase in the intensity of beta-galactosidase expression (ELISA). X-gal staining and immunohistochemistry showed that vector spread was confined to the innermost intercostal musculature. CONCLUSION: Ultrasound-guided injection can deliver gene therapy vectors to the fetal pleural cavity and achieve transduction of the respiratory muscles.

Adenoviridae↗
PubMed2001

Congenital cytomegalovirus infection. Is there a breakthrough?

QUESTION: My 26-year-old patient is planning her first pregnancy in the coming month. She works in a day-care centre. Recently, two cases of cytomegalovirus (CMV) infection were diagnosed in her class. What tests should she have before and during the pregnancy, and how should I care for her? ANSWER: Cytomegalovirus infection, the most common congenital viral infection in humans, carries high risk of long-term morbidity and mortality. Seronegative mothers of children in day-care centres are at as high risk of acquiring the infection as day-care workers themselves. The immune status of at-risk patients should be evaluated as pregnancy progresses. Evidence of fetal infection does not necessarily mean fetal disease or damage. With a primary-infected fetus, termination of pregnancy might be discussed with the parents.

Abortion, Induced↗
PubMed1988

Autosomal recessive polycystic kidney disease in a murine model. A gross and microscopic description.

The C57BL/6J-cpk genetic murine model of autosomal recessive polycystic kidney disease was examined to gain insight into the pathogenesis of renal cystic disease. Fetal through 3-week-old offspring of heterozygote matings were used to study growth parameters and morphology of this genetic form of cystic disease. The kidneys were examined by light and electron microscopy and nephron segments were microdissected. Two phases of cystic disease development were morphologically identified. The first phase in fetal and newborn affected pups was characterized by proximal tubule enlargement and a general increase in the tubular mitotic index. The proximal tubules showed cytologic abnormalities along with an increased necrotic cell index. The later phase, in one through 3-week-old cystic pups, was characterized by progressive enlargement of the kidneys due mainly to cystic change of the collecting ducts and by development of azotemia. Secondary to the azotemia was a stunted body growth. Significant tubular epithelial hyperplasia was not found by mitotic index during the second phase, but an increase in collecting duct cellularity was present. Histone H4 gene expression, which is tightly coupled to DNA synthesis and thus an index of cell proliferation, showed only a minimal increase in cystic kidneys at 1, 2, and 3 weeks of age. Therefore, the degree of cell proliferation necessary to allow the observed tubular enlargement appears to be minimal.

Animals↗
PubMedDate not supplied

Sexually transmitted diseases and pregnancy.

The association of adverse pregnancy outcome with Treponema pallidum, Neisseria gonorrhoeae and herpes simplex infections is well known and specific recommendations for management have been formulated. However, other agents that are not so well known can be transmitted sexually and threaten an otherwise healthy pregnancy. These agents are discussed in order to make the nurse more aware of related maternal and fetal diseases.

Chlamydia Infections↗
PubMed2005

Hematologic and lymphocyte immunophenotypic reference values for normal rhesus monkey (Macaca mulatta) umbilical cord blood; gravidity may play a role in study design.

Hematology and flow cytometry reference values for rhesus umbilical cord blood (UCB) were established in 17 healthy infant rhesus monkeys delivered by elective cesarean section 10 days preterm. The infants were born to age matched, singly caged primigravid or secundigravid dams. The hematology and flow cytometry values were determined by automated cell counter and by FACS. No significant differences were observed with respect to infant gender. With respect to gravida, the primigravid infants had a significantly higher percentage (P= 0.05) of CD20(+) B lymphocytes in UCB. These results provide useful reference values for future studies of maternal - fetal disease transmission, vaccine and drug evaluation in non-human primate pregnancy, as well as fetal programming and immune modulation, gene therapy and the use of UCB as a source of stem cells for research and transplantation. Importantly, our results suggest that maternal gravidity may be an important variable to consider.

Animals↗
PubMed1998

Pharmacological agents in pregnancy to improve fetal conditions: prevention of fetal cardiac insufficiency, consequences of congenital adrenal hyperplasia and respiratory distress syndrome.

Improved prenatal diagnostics of fetal diseases have made it necessary to evaluate and develop maternal pharmacological treatment programs to improve fetal condition. In fetal cardiac insufficiency due to persistent tachyarrhythmias, maternal treatment, e.g., with either digoxin alone or combined with other drugs, makes it possible to continue pregnancy in preterm patients with risk of fetal cardiac failure and decreases mortality and morbidity. The loading dose of digoxin can be given either intravenously to the mother or when fetal hydrops is already present directly into the fetal buttock. Maternal oral treatment is initiated simultaneously and continued until delivery is possible. If no response is achieved in 3 days, other regimens are used. Severe virilization of female fetuses due to congenital adrenal hyperplasia and 21-hydroxylase deficiency can be prevented by starting oral maternal dexamethasone (1.0-1.5 mg/day) treatment no later than at the 7th week of pregnancy. Later analysis of chorion villous cells at the 10-11th week of pregnancy reveals whether the fetus is affected or healthy. If affected, the treatment has to be continued until delivery. Maternal corticosteroid therapy to prevent respiratory distress syndrome (RDS) of preterm infants must be given at least 24-48 hours before delivery to get any benefit. The two regimens used are betamethasone 12 mg twice with an interval of 24 hours, and dexamethasone 12 mg twice with an interval of 12 hours. Serial treatments with an interval of 7-14 days further decrease the risk of RDS, but simultaneously the possibility of side effects such as fetal growth retardation and postnatal endocrinological disorders increases.

Journal Article↗
PubMedDate not supplied

[Prenatal diagnosis of hemoglobinopathies].

Fetal red blood cells are necessary for the antenatal diagnosis of hemoglobinopathies. Fetal blood may be obtained in utero, by amniocentesis or fetoscopy, from the 17th to the 20th week of pregnancy. At this time, biochemical techniques may detect bêta-thalassemia major (fetal synthesis of hemoglobin btaA chain totally absent or less than 2% and sickle cell disease (fetal synthesis of btaS chain, without any production of bêtaA chain). When fetal blood has been severely contaminated by maternal blood, purification techniques allow enrichment of the sample in fetal red blood cells by the elimination of adult reticulocytes which may lead to errors in diagnosis.

Erythrocytes↗
PubMed1999

[Clinical significance of cardiac axis determination in prenatal echocardiographic diagnosis of fetal congenital heart disease].

OBJECTIVE: To investigate the clinical significance of cardiac axis determined by echocardiography in prenatal diagnosis of fetal congenital heart disease (CHD). METHODS: 518 high risk fetuses for CHD were and 90 normal fetuses were examined by echocardiography. Cardiac axis was measured on four-chamber view and fetal cardiac anatomical structure was examined in multiple views to determine CHD. RESULTS: The 35 fetuses with CHD diagnosed by prenatal echocardiography. There is significant difference of caidiac axis between CHD group (58.1 +/- 15.7 degree) and normal group (44.8 +/- 10.3 degree, P < 0.01). Sensitivity of CHD diagnosis using four-chamber view alone is 68.5%, it will be elevated to 91.4% by combination of four-chamber view and cardiac axis determination (P < 0.05). CONCLUSION: Cardiac axis play an important role in fetal echocardiographic screening for CHD and it should be measured routinely as part of the four-chamber view of the fetal heart. The normal range of fetal cardiac axis is 20 to 75 degree. If it was more than 75 degree, the CHD should be suspected.

Adult↗
PubMed1995

[Prenatal diagnosis].

A growing number of methods for the in-utero diagnosis of fetal disease became available during recent decades, mainly due to rapid advances in ultrasound technology and laboratory methods. Exclusion of fetal aneuploidy in pregnancies of women beyond 34 years is still by far the most common reason for an invasive procedure event at a time when the number of diagnosable inborn errors of metabolism and monogenetic disorders is increasing rapidly. Great efforts have been made to improve the poor predictive value of maternal age as an indicator for an increased risk for fetal aneuploidy. Maternal serum screening using various parameters [e.g. AFP, hCG, uE3] has been found effective in identifying the majority of pregnancies with Down syndrome in the second trimester. Current research goals are the optimal choice of markers and the introduction of maternal serum screening in the first trimester of pregnancy. Ultrasound is another suitable tool to identify pregnancies at high risk for aneuploidy at least in the hands of experienced operators. The diagnostic use of fetal cells in the maternal circulation is presently investigated in a large collaborative trial. Second trimester amniocentesis still is the most widely applied invasive technique in pregnancies with maternal age related risks for fetal aneuploidy. Safety and diagnostic accuracy are well established and amniotic fluid can easily be shipped. Without major changes in conventional sampling and laboratory techniques the procedure can be performed at 13 weeks of gestation and later. The safety and efficacy of first-trimester amniocentesis has still to be established in larger series. First-trimester chorionic villus sampling is a well-established alternative to amniocentesis with comparable procedure-related risks. It is the method of first choice in pregnancies at high risk for aneuploidy, inborn errors of metabolism and monogenic disorders, since uncultured villi can be used for a rapid diagnosis. Placental biopsy should also be considered in the second and third trimester of pregnancy for these indications whenever time is a critical issue. Fetal blood obtained by ultrasound-guided cordocentesis has successfully been used for the diagnosis of fetal infection and is at the same time another good source of cells for rapid karyotyping. Other invasive procedures such as fetal skin or liver biopsies for electron microscopy or specific metabolic tests are restricted to the relatively rare instances of diseases where DNA diagnosis is currently not available or uninformative. Providing information on the different alternatives in an individual situation is one of the critical issues in pregnancy care today.

Amniocentesis↗
PubMed1992

[Placental development and viral infections].

The stages of placental development are briefly described as well as the cellular and molecular mechanisms involved in the immunologic defense systems at the maternofetal interface. Methods available for morphologic studies of placentas with viral infection are reviewed. Routes of transmission of viruses from mother to fetus, as well as the placental lesions seen in viral infections are discussed. Emphasis is put on the value of "oriented" pathologic studies of the placenta whenever viral fetal disease is suspected.

Chorionic Villi↗
PubMed1990

First-trimester diagnosis of fetal congenital heart disease by transvaginal two-dimensional and Doppler echocardiography.

Until recently, prenatal diagnosis of fetal cardiac malformations was restricted to the second and third trimesters. With the advent of high-frequency transvaginal probes, earlier detection of such malformations is possible. We present a case of nonimmune hydrops fetalis with complete atrioventricular canal defect, insufficiency of atrioventricular valves, and complete heart block at 11 weeks' gestation diagnosed by transvaginal two-dimensional and Doppler echocardiography.

Adult↗
PubMed1987

Application of DNA-based diagnosis to patient care: the example of hemophilia A.

DNA-based carrier testing and prenatal diagnosis are rapidly expanding medical applications of recombinant-DNA technology. The ultimate goal of DNA-based diagnosis is the determination of the causative mutation, but, in general, this is possible only for large deletions, insertions, or certain nonsense mutation that, in most diseases, involve only a few percent of affected families. If direct diagnosis of the carrier state or fetal disease state is not feasible, indirect diagnosis can be performed by following the segregation of linked polymorphisms through the family pedigree. For such indirect diagnosis, DNA from multiple family members must be analyzed. Although this procedure is highly accurate in many families, errors can potentially occur because of meiotic recombination, genetic heterogeneity, new mutations, and nonpaternity. In this review, a general introduction to DNA-based diagnosis of mendelian diseases is presented and the methods and strategy are outlined. The use of these techniques for the diagnosis of hemophilia A is then described to illustrate the principles of diagnosis and to highlight some of the complexities encountered. DNA-based diagnosis is in its infancy and has the potential to revolutionize preventive medicine.

DNA, Recombinant↗