Perinatal management of a lingual teratoma.

BACKGROUND: Teratomas of the head and neck are rare and occur almost exclusively in neonates. Prenatal diagnosis of these tumors allows for a carefully planned delivery that maintains an open airway and potentially improves perinatal outcome. We report the perinatal management of a huge intrapharyngeal and intra-oral teratoma that had a broad connection to the base of the tongue. CASE: An anterior neck mass (5 x 5 cm) in an otherwise normal-appearing fetus was detected at 19 weeks' gestation. The mass increased in size over the next 10 weeks to 8 x 6.8 x 4.3 cm. Marked fetal head deflexion was noted along with concomitant hydramnios. The mother had spontaneous rupture of membranes with preterm labor at 29 weeks' gestation. A 1860-g male neonate was delivered by classical cesarean delivery. A tracheostomy was performed in the delivery room for ventilation after the upper airway could not be accessed by bronchoscopy. Histologic examination after surgical excision confirmed a congenital teratoma with immature neuroectodermal tissue and alpha-fetoprotein-bearing endodermal sinus tumor components with exclusively polyvesicular vitelline characteristics. The origin of the pharyngeal mass was the base of the tongue. CONCLUSION: The prenatal diagnosis of a pharyngeal teratoma should prompt a careful delivery plan to optimize perinatal outcome.

Cesarean delivery for fetal malformations.

We reviewed existing data on fetal abnormalities to provide guidelines to determine which conditions have an improved neonatal outcome by cesarean delivery. We used Medline database to search for English language papers on a variety of fetal conditions that could influence the mode of delivery. We reviewed these sources with particular attention to how the mode of delivery influenced neonatal outcome. Conflicting data exist regarding optimal mode of delivery for many fetal conditions. Cesarean delivery may improve neonatal outcome for fetuses with isolated meningomyelocele, hydrocephalus with concomitant macrocephaly, anterior wall defects with extracorporeal liver, sacrococcygeal teratomas, hydrops, and alloimmune thrombocytopenia with low platelet count at term. Hydrocephalus without macrocephaly, anterior wall defects without an extracorporeal liver, ovarian cysts, skeletal dysplasias, fetuses whose mothers have immune thrombocytopenic puer-pura and fetuses with alloimmune thrombocytopenia with acceptable platelet counts may safely be delivered vaginally.

Severity, manifestations, and consequences of violence among pregnant adolescents.

PURPOSE: To examine the severity, manifestations, and consequences of prenatal violence among adolescent and adult participants in a county health department prenatal care coordination program. METHODS: The prospective cohort study design included all Medicaid-eligible program participants from 1994 to 1996. Care coordinators screened participants for prenatal violence using a validated, systematic violence assessment protocol at three times during pregnancy. This protocol was linked with prenatal care and hospital delivery records to document pregnancy outcomes. The main outcome variables were low birth weight (<2500 g) and preterm delivery (before 37 weeks' gestation). RESULTS: Among teens, 16.1% reported prenatal violence, including 9.4% who reported severe violence such as hitting, kicking, or stabbing. Among adults, 11.6% reported prenatal violence, including 4.8% who reported severe violence. Teens were more likely than adults to report abdominal trauma (56% vs. 22%) and violence perpetrated by a relative (23% vs. 5%). Teens who reported severe prenatal violence were more likely to report alcohol use. They were significantly more likely to deliver preterm than teens who reported "other" or "no" prenatal violence (odds ratio 3.5, 95% confidence interval 1.1-10.8) when adjusting for race, adequacy of prenatal care, prior preterm delivery, and alcohol use. For adults, the relationship between prenatal violence and preterm delivery was not statistically significant. The relationship between prenatal violence and low birth weight was not significant for either age cohort. CONCLUSIONS: Prenatal violence was a significant risk factor for preterm birth in this population, especially among teens.

Statewide assessment of a behavioral intervention to reduce cigarette smoking by pregnant women.

OBJECTIVE: Smoking in pregnancy is the foremost cause of preventable perinatal mortality. We have demonstrated that a behavioral intervention can alter smoking in pregnant women. We tested the utility of this intervention at multiple sites in varied settings across a suburban-rural state. STUDY DESIGN: We performed a prospective cohort study at 10 prenatal care sites across North Carolina. Carbon monoxide manometry was used to verify cessation; self-report confirmed reduction. Each site enrolled smokers for 1 year. Four outcome predictor variables were studied: clinic volume, prevalence of smoking, physician versus nonphysician intervenors, and public versus private clinics. RESULTS: Smoking prevalence varied from 4% to 85%. Biologically confirmed quit rates ranged from 0% to 45%. The prevalence of smoking within a clinic's population was able to explain differences in reduction (p < 0.01) of smoking between sites. CONCLUSION: We have demonstrated the effectiveness of an intervention to alter smoking behavior in pregnancy. It appears that this technique has the greatest utility in clinics with a high prevalence of smoking.

Transdermal nicotine replacement in pregnancy: maternal pharmacokinetics and fetal effects.

OBJECTIVE: Our purpose was to measure any short-term effects that the transdermal nicotine replacement system may have in pregnancy and to verify salivary nicotine and cotinine levels during patch placement. STUDY DESIGN: After customary smoking cessation efforts had failed, six prenatal patients between 28 and 37 weeks' gestation who smoked between one and two packs per day were enrolled in this prospective study. The patients were admitted to the General Clinical Research Center for a period of 21 hours. During hospitalization we performed maternal and fetal assessments including vital signs, biophysical profile and electronic fetal monitoring, amniotic fluid index, and umbilical artery Doppler examinations. Salivary samples for cotinine and nicotine levels were collected at standard intervals. RESULTS: There were no measurable differences in fetal or maternal well-being. During patch use salivary nicotine levels increased as expected, to a mean value of 19.0 +/- 13.5 micrograms/L at 480 minutes. Salivary cotinine concentrations remained low (approximately 50 micrograms/L) and varied little during the 480-minute period that the patch was worn. Overall, patients were satisfied with the transdermal patches. CONCLUSION: There were no adverse maternal or fetal effects from the transdermal nicotine replacement system over the 6-hour period. Salivary nicotine concentrations were consistent with those seen in nonpregnant adults. Surprisingly, salivary cotinine concentrations were much lower than those seen in smoking nonpregnant adults.

A role for maternal serum screening in detecting chromosomal abnormalities in fetuses with isolated choroid plexus cysts: a prospective multicentre study.

A prospective multicentre study was performed to identify patients with fetal choroid plexus cysts and examine the association between choroid plexus cysts and chromosome abnormalities in the context of variables such as maternal age, serum triple-screen results, race, other prenatally-identified fetal anomalies and cyst characteristics. A total of 18 437 scans were performed in 5 centres and 257 fetuses were identified with choroid plexus cysts. Outcome was available on 250 patients, and of these, chromosomal abnormalities were detected in a total of 13 (5.2 per cent) fetuses. 26 patients in the group had additional ultrasound abnormalities, and 8 of these had fetal chromosome abnormalities. Among the 224 patients with isolated choroid plexus cysts, 5 (2.2 per cent) were found to have chromosomal abnormalities. All cases with identified chromosomal abnormalities were associated with an additional risk factor, such as other ultrasound findings, advanced maternal age or abnormal maternal serum triple-screen results.