Transplacental immunization of the human fetus to tetanus by immunization of the mother.

Experimental studies in rats showed that immunization of the pregnant female led to the transplacental immunization of her fetuses. The possibility that this also occurred in humans was explored by immunizing 42 pregnant women with tetanus toxoid (2.5 or 5 Lf) in the fifth and eighth months of pregnancy and comparing the immune responses of their offspring with the responses of the offspring of 25 unimmunized mothers. Only the offspring of the immunized mothers were sensitized to tetanus. IgM antitetanus antibodies were in their blood before immunization with diphtheria, pertussis, tetanus vaccine (DPT), they had a more rapid (P less than 0.01) response to DPT immunization, and they were still highly sensitized (P less than 0.01) to tetanus 13 mo after birth. In addition, pregnancy had no immunosuppressive effect (P less than 0.05) on the responses of the mothers to tetanus toxoid. Thus, transplacental immunization occurs in humans; it enhances the response of the offspring to subsequent immunization, and it could be used to circumvent the necessity for immunization in early neonatal life.

Intrapartum fever, epidural analgesia and histologic chorioamnionitis.

OBJECTIVE: Our objective was to determine whether epidural analgesia and histologic chorioamnionitis were independent predictors of intrapartum fever. STUDY DESIGN: This secondary analysis, retrospective cohort study included term parturients with placental examination during 2005. Logistic regression used fever (⩾38 °C) as the dependent variable. Significance was defined as P⩽0.05. RESULT: There were 488 (76%) of 641 term parturients with placental examination and epidural. Independent predictors of intrapartum fever were epidural odds ratio (OR)=3.4, confidence interval (CI): 1.70, 6.81, histologic chorioamnionitis OR=3.18, 95% CI: 2.04, 4.95, birthweight OR=2.07, 95%CI: 1.38, 3.12, vaginal exams OR=1.15, 95% CI:1.06, 1.24, duration ruptured membranes OR=1.03, 95% CI: 1.01,1.05, parity⩾1 OR=0.44: 0.29, 0.66 and thick meconium OR=0.35: 95%CI: 0.24, 0.85. CONCLUSION: Epidural analgesia and histologic chorioamnionitis were independent predictors of intrapartum fever. Modification of labor management may reduce the incidence of intrapartum fever.

Left ventricular thrombus and systemic emboli complicating the cardiomyopathy of Duchenne's muscular dystrophy.

A 17-year-old boy with Duchenne's muscular dystrophy and congestive cardiomyopathy with a left ventricular thrombus is described. The patient presented with flank pain, and computed tomography of the abdomen revealed multiple bilateral renal infarcts. An echocardiogram delineated a left ventricular thrombus and generalized hypokinesis with a left ventricular ejection fraction of 25%. Heparin therapy was started, but the patient died of refractory congestive heart failure. Autopsy revealed diffuse skeletal myopathy consistent with Duchenne's muscular dystrophy as well as biventricular cardiomyopathy with a recent left ventricular apical-septal mural thrombus. Right atrial thrombus, a left upper lobe pulmonary embolus, and splenic and renal infarcts were also noted. To our knowledge, this is the first reported case of left ventricular thrombus with or without systemic emboli in the cardiomyopathy of Duchenne's muscular dystrophy.

Surfactant replacement therapy at birth: final analysis of a clinical trial and comparisons with similar trials.

A randomized trial of surfactant replacement therapy at birth was conducted at the University of Rochester between June 1983 and November 1985. Thirty-four premature infants, 25 to 29 weeks' gestational age, received a preventilatory dose of a calf lung surfactant extract in saline prepared at the University of Rochester. A control group of 31 infants received a preventilatory dose of saline alone. The major finding of this trial is that a single preventilatory dose of calf lung surfactant extract reduces the severity of the respiratory distress syndrome during the first 24 hours of life. The beneficial effects, however, are not sustained in many infants and diminish after 24 hours of life. The survival rate was 71% in both the control and surfactant-treated groups. There was a lower incidence of pneumothorax in the surfactant-treated group. There were no differences in the incidence of bronchopulmonary dysplasia, patent ductus arteriosus, and intraventricular hemorrhage. No adverse effects of surfactant replacement therapy were identified. Results of this study suggest that multiple postventilatory doses of surfactant will be required for optimal therapy.

Familial CHARGE syndrome: clinical report with autopsy findings.

We report on a patient with CHARGE syndrome, as manifested by a coloboma of the optic nerve head, congenital heart defect (ASD, VSD, and parachute mitral valve), choanal atresia, severe growth retardation, genital hypoplasia, abnormal ears, cleft lip and palate, and pectus carinatum. His chromosomes were normal. He died at 19 months. His mother was short and had hearing impairment, choanal atresia, and a coloboma. We suggest that this represents evidence for dominant transmission of this disorder in this family. Other familial cases from the literature are reviewed.

Prenatal sonographic diagnosis, Doppler velocimetric umbilical cord studies, and subsequent management of an acardiac twin pregnancy.

Sonographic prenatal diagnosis and management of a twin pregnancy complicated by acardius anceps of one twin and acute polyhydramnios is presented. To our knowledge, this is the first case of an acardiac twin gestation in which Doppler umbilical arterial velocimetric studies were obtained. These studies, performed at 29 weeks' gestation, demonstrated markedly different umbilical artery systolic to end-diastolic (S/D) ratios in the twins. This difference is explained by the vascular resistance reflected in the umbilical artery S/D ratios obtained on each twin. The healthy twin's S/D ratio represented the vascular resistance of the placenta and the perfused acardiac twin. Because of the reversed direction of blood flow in the acardiac twin's umbilical artery, this S/D ratio represented the vascular resistance of the acardiac twin. Planned preterm delivery resulted in survival of the healthy normal twin.

The occurrence of simultaneous fetal heart rate accelerations in twins during nonstress testing.

A prospective study was performed of 152 pairs of nonstress tests (NSTs) obtained simultaneously from both members of 52 twin gestations. Fifty-seven percent of the total fetal heart rate (FHR) accelerations occurred simultaneously in both twins. Between twins, the incidence of simultaneously occurring FHR accelerations was independent of gestational age, growth discordancy, or the type of placenta. For each twin, the number of FHR accelerations remained constant with increasing gestational age. These results may suggest that tactile communication exists in utero between twins.

Prenatal sonographic diagnosis of non-rhizomelic chondrodysplasia punctata.

BACKGROUND: Chondrodysplasia punctata is a rare heterogeneous group of bone dysplasias occurring with an incidence of one in 100,000 live births. Prenatal sonographic diagnosis of non-rhizomelic chondrodysplasia punctata (Conradi-Hünermann syndrome) has previously been reported only following detection of overall limb shortening. CASE: Multiple sonographic skeletal findings of premature epiphyseal calcifications, other unusual calcifications, kyphoscoliosis, and asymmetrical limb shortening, typical of non-rhizomelic chondrodysplasia punctata, led to second-trimester prenatal sonographic diagnosis of this condition. CONCLUSION: Second-trimester prenatal sonographic diagnosis of premature epiphyseal calcifications associated with non-rhizomelic chondrodysplasia punctata is possible.

Congenital ichthyosis with restrictive dermopathy and Gaucher disease: a new syndrome with associated prenatal diagnostic and pathology findings.

BACKGROUND: Since 1988, three nonrelated fatal cases of congenital ichthyosis associated with Gaucher disease have been described in Australia. CASE: We present a case of Gaucher disease with congenital ichthyosis and restrictive dermopathy and describe the associated prenatal sonographic findings and pathology of this new syndrome. CONCLUSION: The unusual association of congenital ichthyosis with lipid storage disease may be suspected prenatally. A high index of suspicion may prove this condition to be more common than previously thought.

Abnormalities in position of left ventricular papillary muscles in congenital aortic stenosis.

Subclinical structural abnormalities may accompany some congenital cardiovascular abnormalities. Echocardiographic observations led us to hypothesize that the positions of the left ventricular papillary muscles are abnormal in hearts with aortic valvar stenosis. To test this hypothesis, we examined 6 normal heart specimens and hearts with congenital cardiovascular malformations, including 5 with pulmonary atresia and an intact ventricular septum, 6 with tetralogy of Fallot and 5 with aortic valvar stenosis. We marked the papillary muscles and the mitral commissures, X-rayed the hearts, and measured the angular positions of the papillary muscles using the midpoint of a chord drawn between the mitral commissures as a reference point. The direction from the midpoint to the lateral commissure was designated as 0 degrees. The data (mean +/- SEM) were analyzed using a computer program (ANOVA). In normal hearts, the anterolateral and posteromedial papillary muscles were positioned, respectively, at 43 +/- 19 degrees and 126 +/- 26 degrees. The positions of the papillary muscles were similar to normal in the hearts with pulmonary atresia (62 +/- 38 degrees and 128 +/- 27 degrees) and tetralogy of Fallot (40 +/- 13 degrees and 130 +/- 37 degrees). In aortic stenosis, the locations of the papillary muscles (-76 +/- 42 degrees and 71 +/- 25 degrees) were significantly different from normal (P less than 0.05). The arc between the papillary muscles was 83 +/- 16 degrees in normals and 147 +/- 45 degrees in aortic stenosis (P less than 0.05). The length of the arc was similar to normal in other heart specimens. Thus, the papillary muscles were abnormally positioned in aortic stenosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Heterotopic supradiaphragmatic liver formation in association with congenital cardiac anomalies.

Heterotopic supradiaphragmatic liver formation is extremely rare. We studied a case of heterotopic liver in a 26-week fetus with severe cardiac and conotruncal anomalies. The cardiac anomalies are strikingly similar to those of a previously described patient with heterotopic supradiaphragmatic liver. The cardiac anomalies and heterotopic supradiaphragmatic liver formation may be mechanistically related.

Acute intrapartum twin-twin transfusion. A case report.

A rare case of acute intrapartum twin-twin transfusion occurred. The well-recognized criteria of long-standing chronic twin-twin transfusion were absent. Although a cesarean section was performed for obstetric reasons, the hyperperfused twin, A, died intrapartum. Twin B, the hypoperfused twin, although liveborn, died neonatally of renal failure attributed to renal cortical necrosis as a sequel to hypotension.

Accuracy of signs of clinical chorioamnionitis in the term parturient.

OBJECTIVE: Uniform histopathologic guidelines were applied to diagnose chorioamnionitis and estimate the accuracy of clinical signs in term parturients. STUDY DESIGN: A retrospective cohort study utilized slides from term parturient placentas with Amniotic Fluid Infection Nosology Committee guidelines as the gold standard. Sensitivity, specificity and accuracy for fever, maternal tachycardia and fetal tachycardia were calculated. RESULT: Of 641 placentas, 367 (57.3%) had histologic chorioamnionitis and 274 (42.7%) were negative. Fever had a sensitivity of 42%, specificity of 86.5% and accuracy of 61%. Fever, maternal tachycardia and fetal tachycardia had a sensitivity of 18.3%, specificity of 98.2% and accuracy of 52.4%. CONCLUSION: Histologic chorioamnionitis, frequently asymptomatic, is a common finding in placentas examined from term parturients. Clinical signs are not accurate in the diagnosis. Adoption of uniform pathologic guidelines will facilitate research into the clinical significance of these lesions in the future.

Lack of mandibular movement manifested by absent fetal swallowing: a possible factor in the pathogenesis of micrognathia.

This study was performed to assess the association of lack of mandibular movement as manifested by absent fetal swallowing and micrognathia in a nonrestrictive intrauterine environment. Over a 5-year period, 14 fetuses with sonographic findings of polyhydramnios (amniotic fluid index [AFI] more than 20 cm), absent mandibular movement, and a nonvisualized fetal stomach, all consistent with absent fetal swallowing, were followed. A group of 14 fetuses, each with polyhydramnios (AFI more than 20 cm), yet with sonographic detection of fetal swallowing, served as controls. All gravidas in both groups were normoglycemic throughout gestation. Subsequent mandibular development was assessed at delivery or autopsy. Analysis of the data revealed that in the study group, 12 of these infants were liveborn, and two were stillborn. Eleven of the liveborn infants had an early neonatal death. All 14 infants of the study group demonstrated micrognathia. None of the control infants (all of whom survived) had micrognathia. In conclusion, this study supports the concept that normal mandibular growth may depend on the presence of mandibular movement during intrauterine development.

Lung disease in the very immature neonate: radiographic and microscopic correlation.

Radiographic-pathologic correlation of pulmonary patterns has not been performed in very small preterm infants below 28 weeks of gestation. The radiologic findings of linear interstitial densities or generalized airspace opacity coincided with histologic changes of edema and hemorrhage and indicate that this is the most frequent abnormality producing radiographic pulmonary opacification in infants of 23-27 weeks gestation. On occasion, parenchymal immaturity alone results in lung opacification, reflecting the established interpretation of diffuse atelecatasis as the histologic-radiographic finding in respiratory distress syndrome.

Maternal prepregnant weight and weight gain: relationship to placental microstructure and morphometric oxygen diffusion capacity.

This study examines the effects of maternal prepregnant weight and gestational weight gain on the size, microstructure, and function of the human placenta. Standard gross, histologic, and histomorphometric techniques were used to examine placentas obtained from the deliveries of 77 poor, black 12- to 30-year-old subjects in relation to maternal prepregnant weight and the rate of maternal weight gain during gestation. The weight, volume, and fetal capillary surface area of the placenta increased significantly in relation to both maternal prepregnant weight and the rate of maternal weight gain during gestation. Prepregnant weight was a more important determinant of placental size and fetal capillary surface area than was the rate of maternal weight gain. The rate of maternal weight gain was a more important determinant of the density of fetal capillary tissues within the placenta and of placental resistance to oxygen diffusion than was prepregnant weight. Both maternal prepregnant weight and the rate of maternal weight gain during gestation relate positively to the size of the placenta, but they have different, potentially complementary effects on placental microstructure and function.

Marked twin-twin transfusion in the absence of nonimmune hydrops.

The precise pathophysiology of development of nonimmune hydrops in either the recipient or donor twin associated with twin-twin transfusion syndrome is not entirely clear. At times the recipient twin may develop nonimmune hydrops, but at other times the donor twin, and infrequently both, may develop this ominous complication. We present an unusual cases of this syndrome in which discordant twins, despite neonatal hematocrit levels of 86 and 21% were both nonhydropic and discuss the possible underlying pathophysiology of this occurrence.

Measurements of ultrasonic pulse arrival time and energy level variations produced by propagation through abdominal wall.

Ultrasonic pulse arrival time and energy level variations introduced by propagation through human abdominal wall specimens have been measured. A hemispheric transducer transmitted an ultrasonic pulse that was detected by a linear array transducer after propagation through an abdominal wall section. The array was translated in the elevation direction to collect data over a two-dimensional aperture. Differences in arrival time and energy level between the measured waveforms and calculated references that account for geometric delay and spreading were found. Plots of waveforms compensated for geometric path, maps of time delay differences and energy level fluctuations, and statistics derived from these for water paths and tissue paths characterize the measurement system and describe the time delay differences and energy level fluctuations caused by 14 different human abdominal wall specimens. Repeated measurements using the same specimens show that individual tissue path measurements are reproducible, the results depend on specimen position, and frozen storage of a specimen for three months does not appear to alter the time delay differences and energy level fluctuations produced by the specimen. Comparison of measurements at room and body temperature indicates that appreciably higher time delay differences occur at body temperature while energy level fluctuations and time delay difference patterns are less affected. For the 14 different abdominal wall specimens, the rms time delay differences and energy level fluctuations have average values of 43.0 ns and 3.30 dB, respectively, and the associated correlation lengths of the time delay differences and energy level fluctuations are 7.90 and 2.28 mm, respectively. The spatial patterns of time delay difference and energy level fluctuation in the reception plane appear largely uncorrelated, although some background variations in energy level fluctuation are similar to features in time delay difference maps. The results provide important new information about the variety and range of ultrasonic wave front arrival and energy variations caused by transmission through abdominal wall.

Absent umbilical artery diastolic flow in a fetus with a partial mole at 18 weeks' gestation.

We present a case in which Doppler velocimetry of the umbilical artery in a fetus with a partial mole at 18 weeks' gestation revealed absent diastolic flow. To the best of our knowledge, this is the first report of Doppler velocimetry of the umbilical artery in this rare condition. Increased placental resistance in this abnormal placenta may explain this finding.

Prenatal diagnosis and subsequent management of a fetus with a 46XY r(4)(p15-q35) karyotype.

Fetal ultrasound examination at 29 weeks' gestation revealed a severely symmetrically growth-retarded fetus with microcephaly, hypertelorism, and hypoplastic genitalia with a two-vessel umbilical cord. G-banding analysis on amniotic cell cultures revealed a 46, XY,r(4)(p15-q35) karyotype in each of the colonies analyzed. This prenatal diagnosis, to our knowledge the first reported, assisted clinical management of this pregnancy.