[The Duplicity of Incidents: Cervical Lymphatic Malformation in two Newborns]. / Die Duplizität der Ereignisse: Zervikale lymphatische Malformation bei zwei Neugeborenen.

We report on two neonates born the same day, both with an isolated cervical lymphatic malformation. Cervical masses were detected by ultrasound late in the third trimester. Following interdisciplinary case conferences, a caesarean section in the presence of a neonatal team was the chosen delivery mode in both cases. Delivery and transition of the newborns were uneventful. The suspected diagnosis was confirmed by postnatal MRIs, which demonstrated neither associated malformations nor compression of vital structures. Therefore, an expectant approach was chosen for the newborn with the smaller lesion. The other newborn featured a sizeable lymphatic malformation, and due to consecutive head tilt, sclerotherapy was initiated in its second week of life. Our case report outlines the challenges of a rare connatal malformation. Guidelines are often missing. Individual decisions regarding delivery mode, diagnostics and therapy have to be made on an interdisciplinary basis and patients as well as parents need counseling and support over a long period. All the more significant is good, interdisciplinary collaboration between the involved disciplines.

[Ethical, Psychosocial and Legal Aspects of the Treatment of Pregnant Patients with Brain Death]. / Ethische, psychosoziale und rechtliche Aspekte der Behandlung hirntoter Schwangerer.

The therapy of brain-dead pregnant women is an extreme example not only of the possibilities in current critical care, but also of resulting ethical, social and legal controversies, an area not familiar to most clinicians. Based on the case of a patient with fatal traumatic brain injury, a previously unknown early pregnancy and stated will to donate organs, we will discuss several aspects using published case reports: therapeutic goals, especially palliative care vs. continuation; implications of brain death diagnosis; considerations on legal care; involvement of relatives, especially the child's father; dynamics within the care team; and finally the issue of putative organ donation. This complex case once more depicts that even facing such highly unfavourable framework and seemingly irreconcilable factors, pregnancy can prevail. The researched facts and considerations in this article are intended to give an overview of potential dilemmas and might serve as a starting point in similar situations.

[Pregnancy and Irreversible Loss of Brain Functions - Case Report]. / Intensivtherapie bei Schwangerer mit irreversiblem Hirnfunktionsausfall.

A 29-year-old woman suffered major traumatic brain injury caused by a car accident. As diagnostic measures had revealed an early pregnancy (9th week), treatment on the intensive care unit was continued for 5 months, after unfavourable cerebral prognosis was followed by an irreversible loss of brain function in the 10th week of pregnancy. After assisted vaginal delivery of a healthy child in the 31th week of pregnancy on the critical care unit, organ procurement took place according to the presumed will of the patient. The article presents the details of the critical care therapy and discusses the supportive medical measures. Those measures served primarily to uphold the pregnancy und support the healthy development and delivery of the fetus and only in second instance the organ preservation aiming on organ donation. Necessary measures included maintenance of vital functions, hemostasis of electrolytes, nutrition, treatment of infection, prevention of adverse effects on the fetus, substitution of hormones and vitamins as well as the preparation of a planned or an unplanned delivery.

Fetal Valproate Syndrome - Still a Problem Today!

Introduction Fetal exposition to valproate can lead to a cluster of facial dysmorphism, congenital anomalies and neurodevelopmental retardation. Case Report In this report we describe 2 cases of fetal valproate syndrome. In the first case, the gravida had a valproate medication before and during pregnancy with additional folic acid. She delivered a male premature infant at 25+2 weeks of gestation due to preterm labor and rupture of the membranes. Physical examination showed even in the premature infant typical signs of fetal valproate syndrome with trigonocephaly, epicanthal folds, broad root of the nose, low-set ears, thin upper lip and anteverted nares. In the second case, the gravida was under antiepileptic therapy with valproate and lamotrigine before and during pregnancy without any prophylaxis with folic acid. Sonographic examination during pregnancy diagnosed a spina bifida, Chiari II malformation and clubfeet. A female newborn was delivered at 39+4 weeks of gestation. Besides the prenatally detected anomalies, facial dysmorphism including microcephaly, low-set ears, thin upper lip and shallow philtrum were seen after birth. Conclusion Valproate, a widely used anticonvulsant medication, is known for its teratogenic effects. The risk of congenital anomalies is even higher in combination with other antiepileptic drugs. Therefore, the avoidance of valproate or at least supplementation with a high dose prophylactic folic acid before and during pregnancy is highly recommended for women with epilepsy.

Regular consumption of Lactobacillus reuteri-containing lozenges reduces pregnancy gingivitis: an RCT.

AIM: This randomized controlled trial assessed the impact of Lactobacillus reuteri on pregnancy gingivitis in healthy women. MATERIALS AND METHODS: Forty-five healthy women (24 test/21 placebo) with pregnancy gingivitis in the third trimester of pregnancy were enrolled. At baseline Gingival Index (GI) and Plaque Index (PlI) were assessed at the Ramfjord teeth and venous blood taken for TNF-α analysis. Subsequently participants were randomly provided with lozenges to be consumed 2 × daily until birth (approx. 7 weeks) containing ≥108 CFU L. reuteri ATCC PTA 5289 and ≥108 CFU L. reuteri DSM 17938 (test) or being devoid of L. reuteri (placebo). Within 2 days after birth recording of GI, PlI and blood sampling were repeated. RESULTS: At baseline, mean GI and mean PlI did not differ significantly between both groups. In the test group mean TNF-α serum level was significantly (p < 0.02) lower than in the placebo group. At reevaluation, mean GI and mean PlI of the test group were both significantly (p < 0.0001) lower than in the placebo group. Mean TNF-α serum level did no longer differ significantly between the groups. CONCLUSIONS: The consumption of L. reuteri lozenges may be a useful adjunct in the control of pregnancy gingivitis.

Prenatal sonographic ultrasound predictors for the outcome in fetal gastroschisis: a retrospective analysis.

PURPOSE: To identify predictive ultrasound signs for unfavorable outcome in fetal gastroschisis (GS). METHODS: This is a retrospective cohort study among pregnant women with the prenatal diagnosis of GS between 1998 and 2011 at the University of Wuerzburg, Germany. Analysis included prenatal ultrasound scans, neonatal intensive care unit (NICU) records, and pediatric records. The collected variables included maternal and fetal demographics, as well as an analysis of predictors for unfavorable fetal outcome. Unfavorable outcome was defined by more than 2 postnatal surgical interventions, intestinal resections, and long time to oral feeding (≥4 weeks). RESULTS: 35 cases of fetal GS were diagnosed, whereby 23 cases met the inclusion criteria and were evaluated by prenatal ultrasound and postnatal outcome. Based on the postnatal situation, 15 patients were classified in a good prognosis group and 8 patients in a poor prognosis group. Fetuses with poor prognosis were presented later during pregnancy (21.1 ± 6 vs. 26.9 ± 5.3 weeks; p < 0.01) and delivered at earlier gestational age (35.6 ± 0.8 vs. 33.4 ± 1.4 weeks; p < 0.01) with lower birth weight (2074 ± 306.3 vs. 2559 ± 255.4 g; p < 0.01). There were no differences in prenatal findings like growth restriction, amniotic fluid index, or Doppler results between good and poor prognosis group. However, early detected and long-lasting bowel dilatation was associated with poor prognosis. CONCLUSION: Late presentation and early gestational age at delivery are associated with poor prognosis in neonates with GS. Furthermore, early onset as well as long duration of bowel dilatation is associated with poor fetal outcome, while other ultrasound characteristics are not able to predict poor prognosis of GS.

Co-Occurence of Reciprocal Translocation and COL2A1 Mutation in a Fetus with Severe Skeletal Dysplasia: Implications for Genetic Counseling.

Achondrogenesis type II is an autosomal-dominant disease leading to severe micromelic dwarfism. Here, we report on the postmortem identification of a de novo heterozygous mutation in the COL2A1 gene (c.1529G>A, p.Gly510Asp) in a fetus who presented with generalized hydrops fetalis and severe micromelia during prenatal sonographic examinations. Initially, a reciprocal translocation t(4;17)(q31;p13) was detected in this fetus by chorionic villus sampling. Subsequent chromosomal analysis of maternal and paternal blood showed that the patient's mother was carrier of the same reciprocal translocation. SNP array analysis of the fetus did not provide evidence for chromosomal imbalances or CNVs that could be associated with the fetal phenotype. The coexistence of a cytogenetic (reciprocal translocation) and a molecular genetic (COL2A1 mutation) abnormality in the fetus carries important implications for genetic counseling.

Severe Brain Damage in a Moderate Preterm Infant as Complication of Post-COVID-19 Response during Pregnancy.

Current evidence from the COVID-19 pandemic suggests that neonatal SARS-coronavirus-2 infections usually have a mild course. Data on how maternal infection during pregnancy affects fetal development are scarce. We present the unique case of a moderate preterm infant with intracranial bleeding and periventricular leukomalacia as a potential consequence of post-COVID-19 hyperinflammation during pregnancy.

Arterial and ductus venosus Doppler in fetuses with absent or reverse end-diastolic flow in the umbilical artery: longitudinal analysis.

OBJECTIVE: To evaluate alterations of arterial and ductus venosus blood flow velocities during deterioration and their interdependence. METHODS: 37 high-risk pregnancies complicated by umbilical absent or reverse end-diastolic flow velocities (AREDV) were monitored by measurement of the pulsatility index of the umbilical artery, middle cerebral artery and ductus venosus waveforms. RESULTS: The mean observation period was 16.5 days. There was a significant change in the pulsatility of waveforms in all vessels over the observation period. Compared with the ductus venosus, pulsatility of waveforms in the middle cerebral artery diverged from the normal range 2.2 weeks earlier. Increase in pulsatility in the umbilical artery was concomitant with venous but not with cerebral flow alterations. In addition, there was a correlation between the increase of venous but not arterial pulsatility and perinatal acidemia. Variability of pulsatility index values of the umbilical artery and the ductus venosus but not of the middle cerebral artery increased towards delivery. CONCLUSIONS: Ductus venosus Doppler allows detection of further deterioration in centralized fetuses with umbilical AREDV. However, striking short-term variability has to be taken into account when considering this parameter.

Arterial and ductus venosus Doppler in fetuses with absent or reverse end-diastolic flow in the umbilical artery: correlation with short-term perinatal outcome.

BACKGROUND: High perinatal morbidity and mortality rates have been reported in association with absent or reverse end-diastolic flow velocities in the umbilical artery. Doppler of fetal venous blood flow might be a helpful instrument for predicting fetal outcome. However, clinical data addressing this issue are rare. Thus, the aim of this study was to evaluate arterial and ductus venosus blood flow velocities as a predictor of short-term outcome in fetuses with umbilical absent or reverse end-diastolic flow velocities. METHODS: Thirty-five high-risk single pregnancies complicated by umbilical absent or reverse end-diastolic flow velocities were monitored by serial measurement of the pulsatility index of the umbilical artery, middle cerebral artery, and ductus venosus waveforms over a period of 1-75 days. RESULTS: The mean observation period between first detection of an umbilical absent or reverse end-diastolic flow velocity and delivery was 8.9 days. A significant correlation was found between parameters of short-term perinatal outcome (art. pH, art. base excess, development of intraventricular hemorrhage, mortality) and end-diastolic flow velocity waveform or pulsatility index of the ductus venosus waveform, but not with arterial Doppler parameters. Gestational age proved to be the best predictor for duration of assisted ventilation and development of respiratory distress syndrome. CONCLUSIONS: Our results indicate that in high-risk pregnancies with umbilical absent or reverse end-diastolic flow velocities, determination of blood flow velocities in the ductus venosus is a useful additional parameter for prediction of fetal outcome and for timing delivery.