Longitudinal evaluation of motor function in patients who underwent prenatal or postnatal neural tube defect repair.

OBJECTIVE: To compare the evolution of motor function from mid-gestation to 12 months of age between prenatally and postnatally repaired cases of open neural tube defect (ONTD). METHODS: This was a retrospective cohort study of all fetuses that underwent prenatal (fetoscopic or open hysterotomy) or postnatal ONTD repair at a single institution between November 2011 and December 2018. The anatomical level of the lesion was defined as the upper bony spinal defect at initial magnetic resonance imaging assessment. Prenatal motor function of the lower extremities was evaluated by ultrasound according to the metameric level of the neurological lesion, based on the methodology of Carreras et al. Fetal motor function was assessed at referral, at 6 weeks after surgery in prenatally repaired cases or 6 weeks after referral in postnatally repaired cases (6-week follow-up) and at the last scan before delivery. In addition, motor function was assessed by a detailed neurological examination at birth and 12 months of age. First sacral (S1) neurological level of the lesion was considered as intact motor function. For statistical comparisons, we attributed numerical scores to each neurological level and motor function was expressed as median (range) neurological level. Motor function (as numerical score) and the proportion of cases with intact motor function and with motor function two or more levels better than expected based on the anatomical level of the lesion were compared between the prenatal- and postnatal-repair groups. Fetal motor function was compared to the anatomical level of the lesion at referral and a better motor function was defined when it was two or more levels better than the anatomical level of the lesion. To assess the evolution of motor function, we compared motor function at referral with that at each follow-up assessment using paired t-tests. RESULTS: We included 127 patients with ONTD, of whom 93 underwent prenatal (51 fetoscopic and 42 open hysterotomy) and 34 postnatal repair. At the time of referral, cases in the prenatal- and postnatal-repair groups presented with a similar anatomical level of lesion (L3 (T9-S1) vs L3 (T7-S1); P = 0.52), similar motor function (S1 (L1-S1) vs S1 (L1-S1); P = 0.52) and a similar proportion of cases with intact motor function (81% vs 79%; P = 0.88) and with motor function two or more levels better than expected based on the anatomical level of the lesion (62% vs 74%; P = 0.24). When compared with prenatally repaired cases, postnatally repaired cases showed worse motor function at birth (S1 (L1-S1) vs L4 (L1-S1); P < 0.01) and at 12 months of age (S1 (L1-S1) vs L4 (L1-S1); P < 0.01). In the prenatal-repair group, motor function remained stable from the time of referral to 12 months of age (P = 0.26). Furthermore, the proportion of patients with intact motor function at referral (81% (75/93)) was similar to that at the 6-week follow-up (74% (64/87)), at the last scan before birth (74% (42/57)), at birth (68% (63/93)) and at 12 months of age (67% (39/58)) in the prenatal-repair group. In the postnatal-repair group, worse motor function, starting from the third trimester to 12 months of age, was observed. The proportion of patients with intact motor function at referral (79% (27/34)) was similar to that at 6-week follow-up (80% (12/15); P = 0.92), but was lower at the last assessment before birth (25% (2/8); P < 0.01), at birth (24% (8/34); P < 0.01) and at 12 months of age (28% (7/25); P < 0.01). Similar findings were noted when assessing the evolution of the proportion of cases with motor function two or more levels better than expected based on the anatomical level of the lesion in each group. CONCLUSIONS: Infants with ONTD that underwent postnatal repair had worse motor function at birth and at 12 months of age than at mid-gestation and when compared with infants that underwent prenatal ONTD repair. Prenatal motor function assessment by ultrasound is an adequate tool to identify those infants who should have a good clinical motor function after delivery. Information obtained by fetal motor function assessment can have an important role for patient counseling and case selection for surgery. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Ciliary body ablation: where are we and how did we get here?

Management of intraocular pressure remains the cornerstone of glaucoma treatment. Related medical and surgical practices involve increasing aqueous outflow or decreasing aqueous production. Filtration procedures that increase aqueous outflow are the first-line surgical defense in glaucoma. However, some cases of glaucoma are resistant to such treatment. In these cases, ciliary body ablation by various methods has had substantial success. Surgical manipulation of aqueous production has been used in glaucoma management since the turn of the century. Techniques have progressed markedly as technology has produced more discrete therapies designed to decrease aqueous production by destroying ciliary body epithelium. Over the past 90 years success has been achieved with a wide range of techniques, from surgical disinsertion of the ciliary body to recent laser and ultrasound techniques. With the development of more precise contact lasers and endoscopic visualization, side effects have been reduced and clinical success rates increased.

Wet smear compared with gram stain diagnosis of bacterial vaginosis in asymptomatic pregnant women.

OBJECTIVE: To compare wet smear and Gram stain diagnoses of bacterial vaginosis among asymptomatic pregnant women. METHODS: Between November 1, 1996 and December 31, 1997, asymptomatic women who initiated prenatal care in our obstetric clinics were invited to participate. Exclusion criteria included antimicrobial use within 2 weeks, cervical cerclage, vaginal bleeding, placenta previa, spermicide use, douching, or intercourse within 8 hours. Clinical diagnosis that required two of three positive criteria for bacterial vaginosis (vaginal pH, whiff test, and clue cells on wet smear) was compared with Gram stain diagnosis (Bacterial vaginosis score 7-10 by Nugent criteria). RESULTS: Population characteristics (n = 69) included an average (+/- standard deviation [SD]) maternal age of 27. 3 +/- 6.6 years, 26 nulliparas (38%), 28 black women (41%), 23 white women (38%), 15 Hispanic women (22%), and three Asian women (4%). The mean (+/-SD) gestational age at entry was 15.6 +/- 7.6 weeks. Twenty-seven percent (18 of 67) of the study population was diagnosed with bacterial vaginosis by definitive Gram stain. Two slides were lost or were of poor quality and not included. Using Gram stain diagnosis of bacterial vaginosis as the standard, clinical diagnosis had sensitivity of 56% (95% confidence interval [CI] 32%, 78%), a specificity of 96% (95% CI 90%, 100%), a positive predictive value of 83%, and a negative predictive value of 85%. CONCLUSION: In asymptomatic pregnant women, bacterial vaginosis can be diagnosed reliably by Gram stain.

Ring block for neonatal circumcision.

OBJECTIVE: To determine whether a difference in the behavioral and physiologic response to circumcision can be demonstrated between neonates undergoing the procedure with ring block and those receiving no anesthesia. METHODS: Forty healthy male newborns were assigned randomly to receive either ring block or no anesthesia. Indices of perceived pain including crying time, behavioral state, oxygen saturation, and heart and respiratory rates were recorded at baseline and at intervals during the circumcision. Infants were reassessed 2 minutes and 2 hours postoperatively. RESULTS: Infants receiving ring block cried less than did controls (P < .001). Anesthetized infants had smaller increases in heart rate (P < .005) and demonstrated less arousal (P < .005) during each operative interval. For all operative intervals combined, anesthetized infants had a smaller decrease in oxygen saturation (P < .001) and a smaller increase in respiratory rate (P = .005) than did controls. Two minutes postoperatively, anesthetized infants had returned to their baseline behavioral state, whereas controls remained significantly more aroused (P < .005). Two hours postoperatively, there were no significant differences in any variables between the groups, nor between each group and its baseline. There were no complications related to anesthesia administration. CONCLUSION: Neonatal circumcision causes behavioral and physiologic changes consistent with the perception of pain. Ring block is an effective method of anesthesia for this procedure.

Angiotensin converting enzyme inhibitors in pregnancy.

Angiotensin converting enzyme (ACE) inhibitors are excellent antihypertensive agents and are becoming widely used as first-line therapy for chronic hypertension in women of reproductive age owing to their efficacy and few side effects. Reports of adverse fetal and neonatal effects from the use of ACE inhibitors in pregnancy in both animal and human studies prompted recommendations against their use in human pregnancy by several authors. This review discusses the mechanism of action of ACE inhibitors and the use of ACE inhibitors in pregnancy both in experimental animals and use in human pregnancy. ACE inhibitors used during pregnancy may have untoward effects on the fetus. Based on reports in the literature, one should avoid starting ACE inhibitors during pregnancy and discontinue them in current users if at all possible.

Controversies in the use of antenatal steroids for fetal maturation.

After decades of caution and reticence, by the early 1990s, the use of antenatal corticosteroids was accepted as a pharmacologic intervention to reduce neonatal morbidity and mortality associated with prematurity. Many prospective studies yielded robust evidence to support the use of corticosteroids for fetal maturation. Their use is no longer disputed. Nevertheless, many unanswered questions remain regarding issues such as the ideal dose, drug form, regimen, or timing of treatment. This article explores many of the unanswered questions associated with antenatal corticosteroid use.

Vaginal birth after cesarean delivery.

VBAC is considered safe and is often successful in carefully selected populations of women. Women with prior CDs are given the option of elective repeat CD or a trial of labor; neither option is risk free. Less morbidity is encountered in women with successful VBACs versus those with elective repeat CD. Patients who undergo successful trials of labor experience fewer blood transfusions, fewer postpartum infections, and shorter hospital stays and generally have no increased perinatal mortality. The high CD rate begins with the high frequency of the first CD. Therefore, a concerted effort should be made to decrease primary CDs. Paul and Miller remind us of the importance of the decision to proceed with the initial CD in their statement, "once a cesarean, always a scar (p 1907)." Many patients present for prenatal care with one or more prior uterine scars. Careful and thoughtful counseling of patients with a previous CD regarding the risks and benefits of a labor trial based on the current available literature is prudent. Pitkin's editorial in Obstetrics and Gynecology in 1991 stated, "Without question, the most remarkable change in obstetric practice over the last decade involves management of the woman with a prior cesarean delivery (p 939)." Controversies regarding the management of women with scarred uteri remain. In his review of the CD controversy, Flamm leaves us with an important thought: "A woman with a prior cesarean is at increased risk regardless of her mode of birth, and eliminating VBAC will not eliminate the risks. Vigilance with respect to primary cesarean delivery is the only way to avoid this dilemma (p 315)."

An abnormal screening ultrasound: concordance with a tertiary obstetrical ultrasound unit.

OBJECTIVE: To determine concordance of ultrasound diagnosis in referrals to a tertiary obstetrical ultrasound unit (TOU) for suspected abnormalities. STUDY DESIGN: Consecutive referrals for "abnormal outside ultrasound" during a 6-month period were compared with the TOU ultrasound diagnosis. Concordance of diagnosis was compared on the basis of organ system involved and referral for single or multiple suspected abnormalities. Chi(2) analysis was used; p < 0.05 was considered significant. RESULTS: Of 104 consecutive referrals reviewed, 42 (40.4%) had no abnormality documented at the TOU. Of the 62 abnormal ultrasound scans at the TOU, 78.3% were concordant. Concordance based on organ system involvement was central nervous system, 30.3%; cardiothoracic, 66.7%; gastrointestinal, 63.6%; genitourinary, 50%. Referrals for a single suspected anomaly were statistically no more likely to have a normal TOU ultrasound scan (40.4%) than those referred for multiple suspected anomalies (36.4%, p > 0.05). CONCLUSIONS: Most referrals to a tertiary center for "abnormal outside ultrasound" will be diagnosed with an abnormality.

Betamethasone alteration of the one-hour glucose challenge test in pregnancy.

OBJECTIVE: To determine if betamethasone administration alters the one-hour (50-g) glucose challenge test (GCT) and, if so, to determine the duration of this effect. STUDY DESIGN: Pregnant women with singleton gestations eligible to receive antenatal betamethasone (24-34 weeks) with no evidence of infection, diabetes mellitus, hepatic or pancreatic disease, betamimetic therapy or prolonged steroid use were invited to participate. Betamethasone (12 mg) was administered intramuscularly upon admission and repeated in 24 hours. After an 8-hour fast, a 50-g GCT was administered 24 hours (day 1) and 72 hours (day 3) after the second betamethasone injection. Plasma glucose samples were drawn one hour after the glucose challenge. Statistical analysis utilized the McNemar exact test. RESULTS: Seven patients, all with normal GCTs 7-10 days outside the study period, were enrolled. Six had abnormal GCT results on day 1 (P = .03). Three had abnormal results on day 3. CONCLUSION: Betamethasone administration results in abnormal one-hour GCTs in pregnant women.

More or less CHAOS: case report and literature review suggesting the existence of a distinct subtype of congenital high airway obstruction syndrome.

Congenital obstruction of the upper airway (CHAOS) is a rare, usually lethal abnormality. A literature review of 36 prenatally diagnosed cases of CHAOS and the analysis of our own case suggest the existence of a distinct subtype of CHAOS, raising important implications for diagnosis and management. Serial fetal ultrasound examinations at 17-23 weeks' gestation showed hyperechoic and enlarged lungs, mediastinal shift, flattened diaphragm, polyhydramnios and apparently fluid-filled esophagus, findings interpreted as bilateral cystic adenomatoid malformation Type III. Ultrasound findings normalized around 32 weeks. The diagnosis of CHAOS was made after birth at term by direct laryngoscopy prompted by ventilatory difficulties and failed attempts at intubation. A pinhole opening posterior to the cricoid cartilage allowed the passage of an endotracheal tube. Based on observations in our case and those of five similar cases in the literature, we describe for the first time a subtype of CHAOS that is characterized by minor pharyngotracheal or laryngotracheal communications and associated with a less severe natural history and even resolution of ultrasound findings. In spite of this, a high index of awareness should be maintained because resolution of ultrasound findings does not necessarily indicate resolution of underlying pathology.

Human immunodeficiency virus-associated nephropathy in pregnancy.

BACKGROUND: Human immunodeficiency virus (HIV)-associated nephropathy typically leads to endstage renal disease requiring dialysis within 3-4 months. This report describes the prenatal course of a patient with HIV-associated nephropathy requiring dialysis during pregnancy. CASE: A 23-year-old nulliparous, black female presented at 13 weeks gestation with a history of HIV-associated nephropathy and anemia. She had a CD4 count of 350/mm(3), a total urinary protein of 1.7 g/day, and a serum creatinine of 4.8 mg/dl. The patient was begun on zidovudine, 500 mg daily, and erythropoietin, 4,000 units weekly. At 23 weeks gestation, when she developed hypertension, a total urinary protein of 3.4 g/day, and a serum creatinine of 4.4 mg/dl, she was hospitalized. Her renal function continued to deteriorate, requiring hemodialysis. At 29-4/7 weeks, she developed preterm labor, for which she was placed on indomethacin. Four days later, at 30 weeks gestation, she delivered a viable male infant. CONCLUSION: HIV-associated nephropathy during pregnancy can be successfully managed with hemodialysis.

Vertical transmission of a Citrobacter infection.

Citrobacter species have rarely been described as-etiological factors of intraamniotic infections. Citrobacter is not a normal inhabitant of the female genital tract. Vertical transmission of Citrobacter from mother to fetus has rarely been reported. A 21-year-old primigravida presented to labor and delivery at 40 6/7 weeks' gestation complaining of ruptured membranes, painful uterine contractions, and fever. An intraamniotic infection was diagnosed and antibiotics begun. She was subsequently delivered of a live male infant. Mother and infant had positive cultures for Citrobacter and overwhelming sepsis. Citrobacter species are rarely described as etiological factors of intraamniotic infections, and vertical transmission has rarely been reported. This pathogen should be considered in cases of chorioamnionitis or maternal sepsis as overwhelming maternal and fetal infection are possible sequelae.

Obstetrical and neonatal outcome in pregnancies after liver transplantation.

The obstetrical and neonatal courses in pregnancies following orthotopic liver transplantation were studied. Maternal and neonatal records were reviewed from six patients (eight pregnancies), cared for by a single practitioner, who had undergone orthotopic liver transplantation prior to pregnancy between 1984 and 1999. Demographic data, reason for transplantation, interval from transplantation to pregnancy, immunosuppressive agents, antepartum complications, and maternal and neonatal outcomes were reviewed. Many reasons for transplantation were noted, and no acute graft rejection occurred. Maternal complications noted were mild renal insufficiency, chronic hypertension, pregestational diabetes, and erythema nodosum. Antepartum complications included oligohydramnios, preterm labor, premature rupture of membranes, severe preeclampsia, fetal growth restriction, multiple congenital anomalies, and intra-amniotic infection. There was one miscarriage at 8 weeks, one previable and one periviable delivery, and the remainder delivered after 34 weeks. In our cohort of patients, once fetal viability was achieved, patients with a prior liver transplant had reasonable maternal and neonatal outcomes.

Perforation of the inferior vena cava by a recently inserted Greenfield filter.

The Greenfield filter is an effective device which provides protection against emboli to the lungs from the deep veins of the lower half of the body. Specific complications, such as perforation, may occur following the placement of caval filters. We report a case of inferior vena cava perforation by a Greenfield filter diagnosed at the time of surgery. With the increasing use of caval filter placement, specific complications such as this will be encountered.

Gallbladder perforation in pregnancy.

Gallbladder perforation is an infrequent but potentially fatal disease. It is extremely rare during pregnancy. We report two cases of gallbladder rupture in the immediate postpartum period and review the literature. The first patient was a 28-year-old polysubstance abuser who presented at 29 weeks' gestation with generalized abdominal pain and ascites. Over a 48-hour period, her abdominal pain increased, and preterm labor and delivery occurred. She had an exploratory laparotomy the day after delivery for persistent abdominal pain and ascites, and a ruptured, gangrenous gallbladder was found. This patient died secondary to complications of the disease. Our second patient had a history of cholelithiasis and developed abdominal pain on the third postpartum day. Three days later, she was taken for exploratory laporatomy and was found to have a ruptured gallbladder. She did well postoperatively. The signs and symptoms of a ruptured gallbladder can be quite confusing in pregnancy. Ultrasonography, ascitic fluid analysis, computed tomography, and magnetic resonance imaging are useful adjuncts in diagnosis. A high index of suspicion, prompt recognition, and early surgical intervention are the mainstays of therapy.

Coagulation studies in patients with marked thrombocytopenia due to severe preeclampsia.

From July 1, 1990, to July 1, 1993, we analyzed the results of fibrinogen levels, prothrombin time, and partial thromboplastin time in patients with severe preeclampsia, at least one platelet count less than 100,000/microL, and no signs of abruption or hemorrhage. Analysis was by Pearson's correlation coefficient and Wald's sequential analysis. We analyzed 162 blood collections from 48 patients. There was no correlation between the level of thrombocytopenia and the levels of prothrombin time, partial thromboplastin time, or fibrinogen. None of the samples from any of the preeclamptic patients demonstrated an abnormal prothrombin time or partial thromboplastin time.

Oral glucose tolerance test and the preparatory diet.

OBJECTIVE: A 3-day diet containing at least 150 g carbohydrate per day has been used in many centers in preparation for the oral glucose tolerance test. The preparatory diet is thought to reduce false-positive diagnoses of gestational diabetes. The purpose of this study was to evaluate the necessity of a 3-day preparatory diet containing > or =150 g carbohydrate in otherwise healthy pregnant patients. STUDY DESIGN: Twenty healthy obstetric patients with abnormal results on a 1-hour glucose challenge test (> or =140 mg/dL) were enrolled in this prospective pilot study. Two oral glucose tolerance tests were administered. The first was with no dietary restrictions, and the second test was performed after a 3-day diet containing at least 150 g carbohydrate. Patients were given a 3-day dietary supplement, which contained 150 g carbohydrate per day. A food diary verified compliance with the diet and indicated other food intake. RESULTS: There was no difference in the number of oral glucose tolerance tests with abnormal results, with or without the diet (5 in each group). Additionally, no significant difference was found in the mean glucose values in the diet versus no-diet groups. CONCLUSION: A preparatory diet does not significantly alter the results of an oral glucose tolerance test administered to healthy pregnant women. The diet unnecessarily delays the diagnosis of gestational diabetes.

Maternal-fetal transfers: indications, appropriateness, and cost.

The objective of this study was to assess the indications, appropriateness, and cost of maternal-fetal transfers to a tertiary care facility in an era of managed care. Our perinatal database was reviewed from January 1, 1996 through June 30, 1997 to determine maternal and fetal indications for transfer, referring institution characteristics, utilization of tertiary level services, and cost of transfer. There were 273 transfers from 53 referring hospitals ranging in distance from <20 miles (n = 102) to >100 miles (n = 41). Thirty-one patients were transferred by air (average cost $7656), 238 by ground (average cost $920), 4 by private car. The referring diagnosis was preterm premature rupture of membranes (PPROM) (n = 80), preterm labor (n = 76), preeclampsia (n = 42), medical complications (n = 25), or other (n = 50). Mean gestational age (GA) at transfer was 28.5+/-5.5 weeks. Patients were referred from hospitals with a self-designated nursery level I (n = 115), II (n = 111), III (n = 45), or none (n = 2). In 42 patients, (15%) no maternal or fetal indication for hospital transfer was identified after evaluation at the tertiary center. The most common referring misdiagnoses were preterm labor (n = 25), PPROM (n = 10) and preeclampsia (n = 3). One hundred and sixty-five patients delivered during transfer admission (mean GA = 29.6+/-4.8 weeks); 79 infants (48%) required admission to a level III, and 52 (31%) to a level II nursery. Most patients require the services of a tertiary facility after maternal fetal transfer. If delivered during transfer admission, the majority of neonates require care in an intermediate or intensive care nursery.