Uterine incarceration during the third trimester: a rare complication of pregnancy.

Uterine incarceration that manifests during the third trimester or at term is a serious and rare complication of pregnancy. The pregnant patient may complain of low-abdominal pain, low-back pain, urinary retention, and constipation, or the patient may be asymptomatic until labor begins. The diagnosis is difficult, and physical findings can be misleading. Ultrasonography and magnetic resonance imaging can be helpful if the anteriorly displaced cervix is clearly depicted. If incarceration of the retroverted uterus persists until term, a cesarean section is necessary. Recurrent uterine incarceration has been reported; therefore, the patient should be monitored closely during subsequent pregnancies. Herein we describe three cases of uterine incarceration during the third trimester and review the literature with respect to incidence, differential diagnosis, management, and complications of this condition.

Anesthesia, cardiopulmonary bypass, and the pregnant patient.

For the perioperative management of pregnant patients with severe cardiac or aortic disease who require a cardiac surgical procedure and cardiopulmonary bypass, a close, cohesive, working relationship must exist among several medical and surgical specialties. For appropriate management, the well-being of both the mother and the fetus must be considered. The best interests of the mother and the fetus may not coincide, and optimal therapy for one may be inappropriate for the other. We present 10 cases of severe cardiac or aortic disease in pregnant women who required surgical intervention. Eight patients underwent cardiopulmonary bypass during pregnancy, and two patients had cesarean section performed immediately before cardiopulmonary bypass. We also discuss the pertinent pharmacologic aspects related to the perioperative period and the management of cardiopulmonary bypass for the pregnant patient.

Management of spontaneous pneumothorax during pregnancy: case report and review of the literature.

Spontaneous pneumothorax rarely occurs during pregnancy. Only 22 nonmalignancy-related cases have been previously published. Herein we report a case of recurrent spontaneous pneumothorax during the third trimester of pregnancy that necessitated surgical intervention. At thoracotomy, a large bulla was excised from the lower lobe of the right lung; abrasive pleurodesis was subsequently done. Postoperatively, the patient had regular contractions, which were successfully stopped with intravenous administration of magnesium sulfate. Indications, procedures, and pre-cautions for operative intervention during pregnancy are discussed.

A genetic review of complete and partial hydatidiform moles and nonmolar triploidy.

Complete and partial hydatidiform moles are genetically aberrant conceptuses. Usually, complete moles have 46 chromosomes (diploidy), all of paternal origin. Most partial moles have 69 chromosomes (triploidy), including 23 of maternal origin and 46 of paternal origin. Triploidy that involves 23 paternal chromosomes and 46 maternal chromosomes is not associated with molar placental changes and, rarely, can result in a live-born infant with multiple birth defects. Herein we review the mechanisms of fertilization that may produce these unbalanced sets of parental chromosomes and the role of genomic imprinting as a possible explanation for these clinical conditions.

Perinatal outcome following intravascular transfusion in severely isoimmunized fetuses.

Twenty-six severely isoimmunized pregnancies managed exclusively with ultrasonographically guided intravascular fetal transfusions are reported. The mean gestational age plus and minus one standard deviation (+/- SD) was 26.3 +/- 3.6 weeks and the mean hematocrit (+/- SD) prior to initial transfusion was 20.6 +/- 6.7%. Four of seven hydropic fetuses and 9 of 19 without hydrops were less than or equal to 26 weeks gestation at the first transfusion. Overall survival was 85% (22/26). Survival was similar whether or not fetal hydrops was present (6/7 vs. 16/19) and whether or not the first transfusion was administered at less than or equal to 26 weeks gestation (10/13 vs. 12/13).

Preterm labor and congenital candidiasis. A case report.

Intrauterine infection with Candida is a rare complication of pregnancy. We report a case of preterm labor associated with Candida chorioamnionitis and the subsequent delivery of an infant with congenital Candida infection. We also discuss possible factors responsible for the increased invasiveness of this usually benign condition and management considerations once the diagnosis is made.

Selective embryo reduction of an interstitial heterotopic gestation.

A case of combined interstitial and intrauterine pregnancy is described. The sonographic finding of a thick myometrial bridge separating a twin pregnancy may be unique to heterotopic cornual pregnancies and is illustrated. The method of selective embryo reduction with potassium chloride to terminate the interstitial pregnancy without damage to the intrauterine pregnancy is also described. The intrauterine pregnancy continued successfully to term.

Factors influencing hemostasis after umbilical vein puncture in vitro.

Bleeding from the site of cordocentesis can be detected by ultrasound examination, but significant hemorrhage into the amniotic fluid rarely occurs. To evaluate the relative contribution of amniotic fluid thromboplastins and the quantity of Wharton's jelly in facilitating coagulation at the puncture site, amniotic fluid samples and umbilical cord segments were obtained at cesarean section from 20 patients. After puncture of the umbilical vein, bleeding times were measured in amniotic fluid and 0.9% sodium chloride. The quantity of Wharton's jelly was assessed by measuring umbilical cord circumference. Mean bleeding times were significantly shorter in amniotic fluid compared with saline solution, but there was no consistent relationship between bleeding times and umbilical cord circumference. We conclude that properties of amniotic fluid facilitate coagulation at the site of umbilical vein puncture.

Absence of hyperinsulinemia in isoimmunized fetuses treated with intravascular transfusion.

We serially sampled blood from fetuses of five severely isoimmunized pregnancies at the time of each intrauterine intravascular transfusion and at birth. We were unable to demonstrate either an elevation in the plasma insulin/glucose ratio or a relationship between the insulin/glucose ratio and hemoglobin concentration at any time period. Plasma total glutathione concentration, however, decreased dramatically from the initial to the second transfusion (323 +/- 114 to 43 +/- 9 ng/ml; t = -5.06, p less than 0.01). We speculate that intrauterine transfusion may modify or prevent the previously reported fetal pancreatic beta-cell hyperplasia and hyperinsulinemia associated with isoimmunization by decreasing red blood cell hemolysis and thereby circulating glutathione.

Cordocentesis: an appraisal of risks.

Fetal blood sampling via cordocentesis is being used with increasing frequency. Between March 1986 and February 1988, we performed 58 intravascular transfusions (64 attempts) and 27 fetal blood samplings (28 attempts) guided by ultrasonography. The complication rates for intravascular transfusion and fetal blood sampling were 9.4% (6 of 64) and 7.1% (2 of 28), respectively. The procedure-related mortality rates were 4.7% (3 of 64) and 0%. We caution that the potential complications be seriously considered when appropriate patients are selected for cordocentesis. Additionally, we recommend that cordocentesis be performed only in tertiary care centers by personnel skilled in both ultrasonography and prenatal diagnosis.

The prevalence of substance abuse in patients with suspected preterm labor.

Premature labor is a recognized complication of substance abuse in pregnancy. However, the prevalence of substance abuse in patients first seen with symptoms of preterm labor and who deny use of illicit drugs is unknown. Between July 1, 1988, and December 15, 1988, 141 patients first seen at Northwestern Memorial Hospital in suspected preterm labor and a comparison group of 108 uncomplicated laboring term patients had urine toxicology screening performed to detect substance abuse. Positive urine toxicology screenings were found in 24 of 141 (17.0%) patients with suspected preterm labor and in 3 of 108 (2.8%) patients in the comparison group. The most common substance identified was cocaine (14/24 and 1/3, respectively). Of those patients in suspected preterm labor, 22 of 86 (25.6%) clinic patients had positive urine toxicology screenings as did 2 of 55 (3.6%) private patients. On the basis of our observations, we recommend that patients admitted in possible preterm labor be encouraged to submit to screening for substance abuse so that appropriate counseling and prenatal and neonatal care become available for these high-risk patients.

Effects of intravascular, intrauterine transfusion on prenatal and postnatal hemolysis and erythropoiesis in severe fetal isoimmunization.

In an investigation of the effects of intrauterine, intravascular transfusions (IUT) on fetal and neonatal hemolysis and erythropoiesis, 12 fetuses who received IUT for treatment of severe isoimmunization had serial measurements of hemoglobin concentration, Kleihauer-Betke stains to detect fetal hemoglobin-containing erythrocytes, and determination of plasma erythropoietin (EPO) concentration before each IUT, at birth, and postnatally. Reticulocyte counts and sensitizing antibody titers were measured in five fetuses. Mean values before the first IUT, before the final IUT, and at birth were as follows: hemoglobin level, 6.1, 9.1, and 11.3 gm/dl; reticulocyte count, 22.7%, 0.5%, and 0.9%; fetal hemoglobin-containing erythrocytes, 100%, 1.6%, and 1.5%; and EPO level, 12, 56, and 756 mU/ml, respectively. Only one neonate required exchange transfusion. In the first month postnatally, all infants had a profound anemia. All but one infant required simple blood transfusions postnatally. Before the first postnatal transfusion, mean hemoglobin concentration was 6.2 gm/dl, mean reticulocyte count was 0.8%, mean erythropoietin concentration was 23 mU/ml, and the sensitizing antibody titer remained markedly elevated. Except for the surge of EPO at birth, EPO levels did not rise prenatally or postnatally unless marked anemia (hemoglobin level less than 5 gm/dl) occurred. These observations suggest that the intrauterine and postnatal anemia in fetuses who receive IUTs may be explained both by hemolysis of newly formed erythrocytes by circulating antibody, which typically persisted for more than a month after birth, and by suppressed erythropoiesis.