Pregnancy complicated by histiocytosis X and preterm labor. Dungan JS, Ferguson II JE. The first reported case in which histiocytosis X was diagnosed during pregnancy is described. Worsening pulmonary symptoms required aggressive evaluation of the patient, including bronchoscopy and open lung biopsy. Preterm labor and diabetes insipidus also complicated this case, and rapid improvement in pulmonary symptomatology followed delivery.
Fetal scalp blood pH sampling has played a valuable role in the development of our understanding of fetal welfare in labor and in the interpretation of electronic fetal heart rate patterns. There is question as to the feasibility of retaining this practice in modern obstetric care because of the advance of science, the general reliance on fetal monitoring criteria for ascertaining fetal well-being, the logistic difficulties involved in obtaining accurate and timely samples, the economic consequences of having to maintain analytic equipment in working order in times of very infrequent use, and the poor correlation between pH alterations and predictable neurologic consequences in the child. As it has all but vanished from use in most clinical care centers, and the principal argument for retaining it ultimately references the physician as the beneficiary, the author proposes that it should be removed from any possible association with purported “standards of care.”
Several recent studies have implicated platelet-activating factor (PAF) in the physiological control of parturition. Because Ca2+ plays a critical role in the pharmacomechanical coupling in smooth muscle, we evaluated the effects of PAF on Ca2+ mobilization in permeabilized human myometrial cells (HMC) and compared this to the action of prostaglandin F2α, (PGF2α), a well-characterized uterotonic agent. Digitonin-permeabilized HMC in the presence of ATP and ruthenium red rapidly sequestered 45Ca to extramitochondrial compartment(s). Exposure of such cells to 10–9–10–6 M PAF or PGF2α caused a rapid, biphasic, and dose-related release of Ca. The action of PAF, but not that of PGF2α, was associated with a similarly rapid, and dose-dependent generation of [3H]-inositol phosphates. The Ca2+-mobilizing effect of PAF, but not that of PGF2α, was blocked by inhibitors of phospholipase C or heparin. Moreover, the combined effect of PGF2α and PAF or PGF2α and Ins(1,4,5)P3 on 45Ca efflux were additive, whereas no such...
As part of the initial diagnostic evaluation of a case of nonimmune hydrops fetalis, primary maternal infection with parvovirus B19 was documented. As no other etiology for the observed fetal abnormalities was found, intrauterine infection with parvovirus was felt to be the cause. Upon follow-up examination, spontaneous resolution of the nonimmune hydrops was noted, and the patient was delivered of a normal infant at term. This case provides additional insight into the natural history of parvovirus infection during pregnancy and documents for the first time that even in a case where the fetus is severely infected, spontaneous in utero recovery may occur.
Objective : Elevation of interleukin (IL)-6 in the amniotic fluid (AF) during the second trimester is associated with increased risk of preterm delivery. AF IL-6 levels of > 2950 pg/ml within 72 h of delivery are predictive of neonatal brain white-matter lesions, such as periventricular leukomalacia (PVL). The objective of this study was to evaluate whether the presence of elevated AF IL-6 during the early second trimester was associated with the occurrence of relevant neonatal morbidity including PVL or perinatal mortality. Methods : We performed a historical cohort study of women who underwent mid-trimester amniocentesis and had known AF IL-6 levels and pregnancy outcome information available. Included were singleton gestations, without fetal structural or chromosomal anomalies. Results : Among the 50 woman-neonate pairs included in the study, six had AF IL-6 levels above 2950 pg/ml. Occurrence of neonatal complications requiring admission to the neonatal intensive care unit (14% vs. 33%, p = 0.1) and perinatal mortality (11% vs. 17%, p = 0.7) were not significantly different between cases with elevated vs. normal AF IL-6 levels, respectively. Only one neonate had evidence of PVL; the mid-trimester AF IL-6 level was 296.9 pg/ml, below the established predictive threshold for PVL. The difference between the rate of PVL observed among cases with elevated AF IL-6 (0/5) and that expected on the basis of the literature (43%) approached statistical significance ( p = 0.08). Conclusions : Elevated mid-trimester AF IL-6 levels do not identify fetuses at risk for relevant neonatal morbidity or perinatal mortality. Larger studies are required to establish whether mid-trimester AF IL-6 levels can predict the occurrence of neonatal brain white-matter lesions.
Objective: Decidual hemorrhage (abruption) is strongly associated with preterm premature rupture of fetal membranes (PPROM). Moreover, thrombin enhances decidual matrix metalloproteinase (MMP) expression, and MMP has been strongly linked to PPROM. The current study sought to determine whether increased thrombin activation, as assessed by circulating maternal plasma thrombin-antithrombin (TAT) complexes, predicted subsequent PPROM. Study design: We conducted a nested, case-control study of plasma TAT levels, measured by sensitive immunoassay, among 27 women with a singleton preterm birth preceded by PPROM and 54 matched, term controls. Receiver operating characteristic curve analysis was performed to identify the optimal TAT cut-off level predicting PPROM. Results: Mean gestational age at delivery in cases was 33.3 weeks, compared to 39.7 weeks in controls (p < 0.001). Compared with controls, women with PPROM had increased median plasma TAT levels in both the second trimester (5.1μg/l (range 2.2-26.3 μg/l) vs. 3.2 μg/l (range 1.3-7.3 μg/l); p = 0.001) and third trimester (7.0 μg/l (range 2.6-85.8 μg/dl) vs. 4.8 μg/l (range 1.7-15.4 μg/dl); p = 0.01). In the PPROM group, 16.0% of the women exhibited bleeding during the pregnancy, while the corresponding value among controls was 3.6% (p = 0.07). In the second trimester, the odds ratio for PPROM with a TAT level of > 3.9 μg/l was 6.0 (95% CI 1.67-21.1). This value predicted PPROM with a sensitivity of 88%, specificity of 68% and positive and negative predictive values of 82% and 97%, respectively. Conclusion: Second-trimester elevated plasma TAT concentrations are predictive of subsequent PPROM. These data provide further evidence that PPROM is associated with decidual thrombin activation.
We describe the antenatal diagnosis of a fetus with mirror-image dextrocardia, complete situs inversus and Turner's mosaicism (45,XO/46,XY) that was artificially terminated at 19 weeks. Autopsy confirmed our initial findings. This case represents an unusual combination of anomalies rarely encountered in clinical practice.
OBJECTIVE:To determine the cost effectiveness of implementing fetal fibronectin testing in women with threatened preterm labor. METHODS:We developed a cost analysis model based upon our institution's experience with threatened preterm labor. Model estimates related to fetal fibronectin were obtained from the literature. The model considered hospital admission and assay cost. RESULTS:Approximately 2000 women deliver annually at our tertiary care facility. In the prior 11 months, 340 (19%) presented for threatened preterm labor with 45 (13%) admissions. In a group of individuals with threatened preterm labor and < 3 cm cervical dilatation, approximately 25% can be expected to have a positive fetal fibronectin test. If fetal fibronectin testing were used to influence the decision of admission, 93 (25%) would have a positive test over a 12-month period, potentially increasing admissions by 94%. At a cost of $225 per test, our institution's antepartum admission cost of $1919, a prevalence of threatened preterm labor of 19% and admission rate of 13%, fetal fibronectin testing applied prior to the decision to admit would result in a total cost of $262 583 with 373 assays performed, and 93 admissions. If only those who would have been admitted based on traditional criteria are considered, > 25% should have a positive fetal fibronectin test. If we assume a positive rate of 70%, fetal fibronectin testing employed after the decision to admit would result in a total cost of $75 963, with 48 assays performed and 34 admissions. Without using the assay, total costs are $92 950 for 48 admissions. CONCLUSION:This cost analysis suggests that fetal fibronectin testing on all patients presenting with threatened preterm labor significantly increases the cost, while fetal fibronectin testing after the decision to admit may reduce the cost.
OBJECTIVE:To compare maternal serum levels of two markers of collagen synthesis, procollagen I carboxy-terminal peptide (PICP) and procollagen III amino-terminal peptide (PIIINP), in patients with pre-eclampsia and in controls.METHODS:PICP and PIIINP were measured by radioimmunoassay in maternal serum samples from patients diagnosed with pre-eclampsia at 32 weeks' gestation or later and in controls from the same period of gestation. For PICP, 37 cases and 36 controls were studied; for PIIINP, 12 cases and 19 controls were studied.RESULTS:Both PICP and PIIINP levels were significantly elevated in patients with pre-eclampsia. PICP and PIIINP levels were, on average, 20% and 80% higher than in controls, respectively.CONCLUSIONS:These results are in agreement with previous findings that maternal serum levels of PICP and PIIINP are mildly elevated in patients with pre-eclampsia. These markers are unlikely to be useful in the prediction of pre-eclampsia.
OBJECTIVE:To develop a reliable office technique for measuring central body fat in postpartum adolescents, we compared: first, a direct sonographic measurement of visceral adiposity to measurements of visceral and subcutaneous abdominal adiposity by computed tomography (CT); and second, skinfold caliper and sonographic measurements of subcutaneous adipose tissue distribution to CT measurements of visceral and subcutaneous abdominal adiposity.METHODS:Postpartum adipose tissue distribution was assessed in 15 teenagers by measuring the thickness of the subcutaneous fat at six body sites with skinfold calipers and ultrasound. Visceral adiposity was measured directly by ultrasound and CT. Taking the CT measurements as the standards, Pearson correlations and regression analyses were used to compare ultrasound measurement of visceral adiposity and the skinfold caliper and sonographic measurements of subcutaneous adipose tissue distribution.RESULTS:All of the adiposity measurements correlated significantly with the two CT measurements. The correlations between the ultrasound and the two CT measurements of abdominal adiposity were weaker than the correlations between the skinfold caliper and the sonographic determinations of subcutaneous adiposity and the two CT measurements of abdominal adiposity. Multivariate analyses identified the sonographic determination of subcutaneous adiposity at the costal site as the best independent predictor of central adiposity.CONCLUSIONS:The results of this study do not support the validity of ultrasound measurement of visceral adiposity as a measure of central adiposity in postpartum teenagers, but do suggest that sonographic determinations of subcutaneous adiposity could be useful for conducting epidemiological studies of the metabolic sequelae of gestational weight gain in this high-risk population of young women.
Lung cancer diagnosed in pregnancy is rare. The number of reported cases has been escalating in recent years, probably reflecting the increasing number of women of reproductive age who smoke. This review presents three cases of lung cancer in pregnancy with different manifestations and outcomes, with a review of the literature. Physicians should have a low threshold using different diagnostic tools for investigating unusual symptoms during pregnancy without fear for fetal safety. Once diagnosed, lung cancer represents a major ethical and medical dilemma. The optimal management of lung cancer in pregnancy is not known, because of the rarity of the cases reported during pregnancy and insufficient follow-up data.
Uterine rupture is a serious and often tragic complication that is life threatening to both mother and child. It occurs at a frequency of around 1% in patients with a previously scarred uterus. Rupture of an unscarred uterus is an unexpected and devastating complication of pregnancy. With the increased use of misoprostol as a labor-inducing agent, cases of rupture of an unscarred uterus following its use have been published in the literature. We report a case of uterine rupture in a multigravid woman with an intrauterine fetal death at 29 weeks' gestation whose labor was induced with misoprostol. A review of all cases of uterine rupture with misoprostol induction is also included. Excessive doses of misoprostol should be used with extreme caution in multiparous women and in patients with a previously scarred uterus even in the context of intrauterine fetal death or termination of pregnancy.
OBJECTIVE:The aim of this study was to follow up the 19 infants born in Tyrol province with abdominal wall defects between 1985 and 1996 whose malformation had been diagnosed prenatally, who were operated on immediately postpartum and who are alive today.METHOD:There were seven children in the omphalocele group and 12 in the gastroschisis group; 18 parents of affected infants took part in the study.RESULTS:Four out of seven children with omphalocele had major associated malformations (two Beckwith-Wiedemann syndrome, one porencephalic cyst, one with skeletal defects). These children presented handicaps related to the associated malformations but not to the abdominal wall defect. The three other children with omphalocele are developing normally. Five out of 11 children with gastroschisis had associated intestinal but no extraintestinal malformations. After discharge, ten of 11 children with gastroschisis were developing normally; one child shows signs of mental retardation. Of 14 mothers who had originally planned another pregnancy prior to the birth of the malformed child, nine decided against becoming pregnant again; the others delayed a further pregnancy for several years.CONCLUSIONS:In our group, associated malformations were the main factor affecting the long-term quality of life of children with omphalocele and gastroschisis. Although most of the children were developing normally, fear of a repetition of the malformation in a subsequent pregnancy dominated reproductive choices in all couples.
Objective : This study tests the hypothesis that chronic inflammatory foci in the placentas of siblings that undergo multifetal pregnancy reduction are associated with shortened gestational length. Methods : Among 446 patients who underwent multifetal pregnancy reduction (MPR), 56 delivered at Mount Sinai Hospital, 37 (66%) had their placentas referred to surgical pathology and 29 (78%) of the 37 patients had tissue sampled from the placenta of the reduced sibling. Slides were reviewed (by C.M.S.) blinded to clinical data. Lesions were diagnosed using previously published criteria. Specifically, inflammatory lesions were correlated with the various perinatal parameters. Non-parametric testing considered p < 0.05 to be significant. Results : Ten (35%) of 29 patients had chronic inflammation in the reduced placenta. Their gestational age at delivery was 33.1 - 3.2 weeks, compared to 35.8 - 2.3 weeks in those without chronic inflammation ( Z = m 2.53, p = 0.01). There was no difference between the cases with and those without chronic inflammation in the reduced placenta, in regard to past reproductive history or clinical assessment of the MPR procedure (e.g. the number of attempts, duration of the procedure, or post-procedural complications). Conclusion : The majority of patients who underwent MPR did not develop a chronic inflammatory response to the process of 'resorbing' the placental tissues of the reduced sibling. However, a significant number (35%) of women who delivered viable offspring after MPR had chronic inflammation in the placenta, and had a shortened gestational length.
Uterine rupture can occur at any time throughout gestation. We present a woman with a previous Cesarean section followed by an abdominal pregnancy. In her next pregnancy, complete uterine rupture resulted in an emergency laparotomy. This case is unique in that it gives insight into the variable presentations of uterine rupture and the risks associated with prior Cesarean sections.
OBJECTIVE:To characterize serial findings of the middle cerebral artery (MCA) and umbilical artery (UA) flow patterns, their relationship to each other, and neonatal outcomes in growth-restricted fetuses. METHODS:Serial pulsatility indices (PIs) from MCA and UA Doppler waveforms were measured in 41 growth-restricted fetuses until Cesarean delivery. We found three patterns, as follows: phase 1 (n = 27), UA PI < MCA PI (no brain-sparing effect); phase 2 (n = 11), UA PI > MCA PI (brain-sparing effect); phase 3 (n = 3), both PIs elevated with the absence of end-diastolic flow or presence of reverse end-diastolic flow, which was designated as the 'breakdown of the brain-sparing effect'. Umbilical cord blood gas data at delivery were compared between each group. RESULTS:Age at delivery and body weights were significantly different for each phase. The mean body weights in all phases were significantly diminished from Japanese standard body weights, indicating growth restriction. The phase 3 pH and base excess were significantly different from those of the other two phases. CONCLUSIONS:Growth-restricted fetuses which suffered from the state of breakdown of the brain-sparing effect were delivered early with severe growth restriction and mild metabolic acidosis. The change from decreased to increased MCA PI along with increasing UA PI may predict a severely growth-restricted infant.
Objective : Enolase is a dimeric cytoplasmic enzyme whose double n isoenzyme, neuron-specific enolase, is predominantly found in neuronal and neuroendocrine tissues. Cell injury causes its release into the blood and cerebrospinal fluid (CSF). Neuron-specific enolase has been measured in the serum and CSF of adults and full-term asphyxiated neonates as a marker of neurological injury. We recently observed an elevation of neuron-specific enolase in the amniotic fluid of women whose neonates subsequently developed intraventricular hemorrhage or periventricular leukomalacia. The purpose of our study was to establish reference values of neuron-specific enolase in the amniotic fluid as a function of gestational age. Methods : A total of 110 amniotic fluid samples, obtained primarily for genetic studies (16-20 weeks, n = 22), for evaluation of preterm labor (21-35 weeks, n = 66) and for fetal lung maturity studies (36-40 weeks, n = 22), were analyzed for neuron-specific enolase. Samples were from women who subsequently delivered term neonates with normal neurological examinations or who delivered preterm neonates with normal neurosonograms up to the 7th day of life. Descriptive statistics and non-parametric correlations were used for analysis. Results : There was no correlation between gestational age and concentration of neuron-specific enolase (Spearman's r = 0.059, p = 0.63). The overall mean neuron-specific enolase value was 2.5 - 1.39 w g/l. The highest value obtained was 6 w g/l. Of the 110 women, 105 (95.5%) had neuronspecific enolase values of less than 5 w g/l, while five (4.5%) had values ranging from 5 to 6 w g/l. Conclusions : The amniotic fluid level of neuron-specific enolase does not change as a function of gestational age. These stable levels may have utility in the evaluation of cases with fetal neurological injury.
OBJECTIVE:To develop a model for prediction of preterm delivery in patients treated with parenteral tocolysis using combinations of maternal demographic and clinical factors.METHODS:We performed a retrospective cohort study using a perinatal database to identify women admitted with preterm labor and treated with parenteral tocolysis from 1980 to 1994. We developed an explanatory model using multiple logistic regression to determine the effect of four variables (prior preterm delivery, substance abuse, maternal complications and third-trimester care) on the likelihood of preterm delivery. For the prediction model, we initially included these four variables and then removed them in a stepwise fashion to determine the combination of the variables that offered the greatest model sensitivity and specificity.RESULTS:A total of 900 women were identified for the study and 247 (27%) had a preterm delivery. In the explanatory model, prior preterm delivery (OR 2.4; 95% CI 1.5-3.6), substance abuse (OR 2.2; 95% CI 1.2-5.1), initiation of care in the third trimester (OR 2.0; 95% CI 1.3-2.8) and medical complications of pregnancy (OR 1.8; 95% CI 1.2-2.6) increased the likelihood of preterm delivery. For the prediction tool, a three-variable model (prior preterm delivery, substance abuse and initiation of care in the third trimester) had high specificity (98%) and modest negative predictive value (73%).CONCLUSIONS:A simple three-variable model can correctly identify 98% of women with preterm labor treated with parenteral tocolysis who will not deliver preterm. Patients with no prior history of preterm delivery, no substance abuse and initiation of prenatal care before the third trimester have a 73% probability of not delivering preterm.
