Objective: To describe a previously unreported isolated congenital cervical diverticulum and its gynecologic, reproductive, and obstetrical implications.Design: Case report.Setting: A university hospital.Patient: A 31-year-old woman presenting with menometrorrhagia and primary infertility. Investigation revealed an isolated collecting cervical diverticulum causing prolonged postmenstrual spotting, possibly interfering with sperm capacitation and access to the uterine cavity.Intervention(s): The examination included hysterosalpingography and magnetic resonance imaging. The combined hysteroscopy and laparoscopy revealed a 5 x 5 cm cervical diverticulum, around 1 cm from the external cervical os, leading to a short cervical canal connected to a normal uterine cavity. The patient achieved a pregnancy after controlled ovarian hyperstimulation and ultrasonographically guided intrauterine insemination.Main Outcome Measure(s): Pregnancy and obstetrical outcome.Result(s): Extensive evaluation revealed the patient's condition to be a previously undescribed congenital cervical anomaly. The patient's infertility was corrected by ovulation induction and sonographically guided intrauterine insemination, which resulted in a twin pregnancy. After 27 weeks of gestation, preterm labor complicated the delivery.Conclusion(s): The diagnosis and management of this unusual congenital cervical diverticulum present a particular challenge, as this congenital abnormality has not been previously described or reported. (Fertil Steril(R) 2002;77:179-82. (C) 2002 by American Society for Reproductive Medicine).

OBJECTIVEThe purpose of this study was to compare maternal and neonatal complications in spontaneous versus in vitro fertilization twins.STUDY DESIGNTwin gestations that were delivered from 1995 to 2000 were reviewed. Cases consisted of 56 in vitro fertilization twins, each of which was matched to two control mothers by age and parity. They were compared regarding various maternal and neonatal complications.RESULTSIn vitro fertilization twins were more likely to have preterm labor compared with control twins, with no difference in the incidences of pregnancy-induced hypertension, gestational diabetes mellitus, placenta previa, or preterm premature rupture of membranes between the two groups. The cesarean delivery rate was significantly higher in cases of twins who were conceived by in vitro fertilization (76.8% vs 58.0%, P=.026), despite a similar rate of elective cesarean delivery and the incidence of nonvertex twin A in both groups. The preterm delivery rate was significantly higher (67.9% vs 41.1%, P=.002) and the gestational age was significantly lower (35+/-3 weeks vs 36+/-3 weeks, P=.043) in cases compared with control subjects. Both twins were, on the average, 230 g lighter in the in vitro fertilization group compared with the control group. However, intrauterine growth restriction was more frequent in the control group (36.6% vs 25%, P=.044). There was a significantly higher incidence of admission to the neonatal intensive care unit, respiratory distress syndrome, a need for mechanical ventilation, and pneumothorax in cases compared with control subjects.CONCLUSIONWhen compared with spontaneous twins, in vitro fertilization twins are more likely to be delivered by cesarean delivery and to have a higher incidence of preterm birth and prematurity-related respiratory complications with a longer nursery stay.

Renal tubular acidosis in pregnancy is a very rare disorder. Most cases are either inherited or secondary to maternal disease or ingestion of toxic chemicals. We report a 22-year-old woman, previously healthy, who presented at 27 weeks of gestation with preterm labor. Investigation revealed renal tubular acidosis with no obvious etiology. Labor was stopped with various tocolytic drugs and her electrolyte imbalance was corrected. She was delivered at 36 weeks, by cesarean for a nonreassuring fetal heart tracing, of an appropriate-for-gestational-age infant weighing 2905 g. Evaluation 3 and 6 months postpartum revealed gradual, but complete resolution of the acidosis and electrolyte abnormality. The infant is now 7 months old, is growing normally with normal electrolytes, and with no evidence of acidosis.

OBJECTIVES:The objective of this study was to compare the efficacy and safety of two dosing regimens of misoprostol for cervical ripening and labor induction.METHODS:Patients who fulfilled the study criteria were randomized to received misoprostol 25 microg or 50 microg intravaginally every 3 h for a total of eight doses for cervical ripening or until labor was established. Endpoints for successful cervical ripening was achievement of Bishop score of nine or greater, and for labor induction reaching the active phase of labor in the first 24 h. The rates of success, duration of first and second stages of labor, type of delivery, significant side effects, and neonatal outcome were measured and compared between the two study groups. Two hundred and fifty-one patients were randomized in two groups--126 received 50 microg and 125 received 25 microg misoprostol. Demographics of the two study groups were similar.RESULTS:Patients in the 50 microg group had a shorter first stage (848 min vs. 1,122 min, P < 0.007), shorter induction-to-vaginal delivery interval (933 min vs. 1,194 min, P < 0.013), decreased incidence of oxytocin augmentation (53.9% vs. 68%, P < 0.015), and decreased total units of oxytocin (2,763 mU vs. 5,236 mU, P < 0.023), but there was a higher hyperstimulation rate (19% vs. 7.2%, P < 0.005).CONCLUSIONS:Successful induction rate, delivery types, and fetal outcome were similar in both groups. Although the rate of vaginal delivery and neonatal outcome were similar in both groups, the 50 microg regimen had shorter first and second stages of labor, and a higher hyperstimulation rate that was easily manageable, allowing for flexibility in using the higher dose in low-risk pregnancies.

Objectives: The study's objectives were as follows: (1) to determine the rate of vaginal delivery after labor induction in severe preeclampsia remote from term and (2) to determine potential predictors of success. Study Design: Retrospective chart review was conducted on live-born singleton pregnancies complicated by severe preeclampsia and delivered at 24 to 34 weeks' gestation from January 1, 1992, to December 31, 1996. Exclusion criteria included eclampsia, presence of labor or spontaneous rupture of membranes on admission, and complication of pregnancy by an ultrasonographically detected fetal congenital anomaly. Patients were divided into 3 groups: elective cesarean delivery without labor, cesarean delivery after labor induction, and vaginal delivery after labor induction. Statistical analyses included multiple logistic regression, the Student t test, the χ2 test, and the Mann-Whitney test. P ≤ .05 was considered significant. Results: A total of 306 charts were reviewed. Among these, 161 patients (52.6%) underwent elective cesarean delivery without labor; the 2 most common indications were unfavorable cervix (33.5%) and malpresentation (22.4%). The remaining 145 patients (47.4%) underwent labor induction with a 48.3% rate of vaginal delivery after induction, ranging from 31.6% at ≤28 weeks' gestation to 62.5% at >32 weeks' gestation. The most common indication for cesarean delivery after induction, in 50.7% of the cases, was nonreassuring fetal heart rate. The median Bishop score was significantly higher (3 vs 2, P = .004) and the total hospital stay was significantly shorter in the vaginal delivery after induction group than in the cesarean delivery after induction group. However, there were no significant differences between the 2 groups in use of cervical ripening agents, gestational age at delivery, birth weight, 5-minute Apgar score, or postpartum endometritis. After exclusion of cesarean deliveries performed for malpresentation, there was no statistically significant difference in classic incision rates between the elective cesarean delivery without labor and cesarean delivery after induction groups (13.6% vs 6.8%; P = .137). According to logistic regression analysis, only the Bishop score was significantly associated with a successful induction (odds ratio 1.38, 95% confidence interval 1.11-1.71). Gestational age reached marginal significance (odds ratio 1.30, 95% confidence interval 0.89-1.89). Conclusions: (1) Labor induction should be considered a reasonable option for patients with severe preeclampsia at ≤34 weeks' gestation because 48% of patients given the chance were successfully delivered vaginally. (2) The Bishop score on admission is the best predictor of success, although the chance of successful labor induction increases with advancing gestational age. (Am J Obstet Gynecol 1998;179:1210-3.)

The incidence of masses in pregnancy is estimated to occur in 1/81 to 1/2,500 pregnancies. The development of colorectal carcinoma during pregnancy is a more rare event, with less than 30 cases above the peritoneal reflection reported in the last 70 years. The differential diagnosis of mucinous adenocarcinoma of ovarian vs. gastrointestinal origin is often difficult. We report a pregnant patient affected by advanced colorectal cancer, who presented with an asymptomatic unilateral adnexal mass on ultrasound. A 28-year old woman was referred to our hospital after a routine ultrasound examination at 26 weeks gestation showing a right adnexal mass. At elective exploratory laparotomy, the patient was found to have metastatic mucinous adenocarcinoma. Diagnostic and treatment choices of such a cancer in a pregnant patient were explored. The final diagnosis of colorectal cancer was made only at the time of a subsequent emergency laparotomy. The goal of an obstetrician/gynecologist and other care givers of pregnant patients, is to achieve a healthy mother and child. Unfortunately, physicians may unwillingly sacrifice the health of the mother by denying or delaying her procedures or treatments simply because she is pregnant. It is especially important in the case of adnexal masses and their related pathology, due to the difficulty in detection and management of such cases during pregnancy, that doctors actively assume the responsibility of assuring that pregnant patients receive the proper care they need.

OBJECTIVES: Our purpose was (1) to assess the influence of delivery route on neonatal outcome in fetuses with gastroschisis and (2) to correlate ultrasonographic appearance of fetal bowel with immediate postnatal ourcome.STUDY DESIGN: Forty-seven cases (1986 to 1994) were reviewed; three abortions and two stillbirths were excluded. Ultrasonographic appearance of fetal bowel (small bowel dilatation >10 mm) was evaluated in 27 cases.RESULTS: Twenty-six infants (61.9%) were delivered vaginally and 16(38.1%) by cesarean section (11 elective, 5 in labor). Delivery route was not significantly associated with indicators of neonatal outcome (rate of primary closure, postoperative complications, days of parenteral nutrition, days to oral feeding, hospital days, or mortality). When ultrasonographic appearance of fetal bowel was correlated with outcome, fetuses with prenatally dilated bower had significantly more bowel edema at birth (p = 0.038), longer operative time (p = 0.013), and higher overall rate of postoperative complications (p = 0.037).CONCLUSIONS: (1) Elective cesarean delivery does not improve neonatal outcome in infants with gastroschisis. (2) Abnormal ultrasonographic appearance of fetal bowel is associated with a more difficult repair and a higher overall incidence of postoperative complications

Caudal regression syndrome represents a continuum of congenital malformations ranging from agenesis of the lumbosacral spine to the most severe cases of sirenomelia with lower extremities fusion and major visceral anomalies. The etiology of this syndrome is not well known. Maternal diabetes, genetic predisposition, and vascular hypoperfusion have been suggested as possible causative factors. The degree of associated anomalies usually parallels the severity of the primary defect. Ultrasonography is the diagnostic tool of choice revealing the absent distal vertebrae of the fetal spine. Amnioinfusion and magnetic resonance imaging (MRI) are of help in better evaluation of the fetal anatomy in cases with oligohydramnios. Perinatal management depends mainly on gestational age at diagnosis and severity of the lesion. It should include genetic counseling and serial sonography to assess interval growth and amniotic fluid volume. Surviving infants have usually a normal mental function and they require extensive urologic and orthopedic assistance. Their long-term morbidity consists mostly of neurogenic bladder dysfunction resulting in progressive renal damage and disabling neuromuscular deficits of the lower extremities. Neurosurgical and orthopedic intervention with physical rehabilitation is indicated to improve the quality of their lives.

Intraligamentary pregnancy, although rare, tests the physician's acumen in diagnostic and therapeutic skills. Two cases illustrating this entity are presented, the first involves an 18-week fetus, the second a partial hydatidiform mole. Although their presentation and pathogenesis may be indistinguishable, their clinical course and management is different. To the best of our knowledge, this is the first reported case of an intraligamentary pregnancy involving a partial hydatidiform mole.