Intrauterine Adenosine Administration for the Treatment of Fetal Supraventricular Tachycardia in a Fetus With Aortic Stenosis.

Fetal tachyarrhythmia and aortic stenosis (AS) both disrupt fetal hemodynamics, leading to congestive heart failure, hydrops, and intrauterine demise. Traditional transplacental treatments for fetal supraventricular tachycardia (SVT) include digoxin, flecainide, and sotalol. However, the treatment of fetal SVT in the setting of AS has not been described, particularly in cases of refractory SVT. We present a case of a 27-year-old nulliparous female carrying a fetus with fetal AS diagnosed at 25 weeks of gestational age (GA). The patient was not a candidate for in utero valvuloplasty. During ultrasound monitoring at 32 and 6/7 weeks of gestation, fetal SVT with a heart rate of 230-260 beats per minute (bpm) was diagnosed. Maternal digoxin was initiated, and sotalol was subsequently added. Due to persistent fetal SVT and a worsening cardiac function, the patient was treated with direct adenosine administration via cordocentesis successfully terminating the fetal arrhythmia. Despite continued transplacental treatment with digoxin and sotalol throughout the course of pregnancy, the fetal SVT recurred at 35 and 5/7 weeks of gestation prompting delivery. Our case illustrates the use of direct intrauterine adenosine as a novel treatment for refractory fetal SVT in the setting of congenital aortic stenosis and concern about progression to fetal hydrops and fetal demise.

Impact of an accessory cavitated uterine mass on fertility: case presentation and review of the literature.

Objective: We report a case of an accessory cavitated uterine mass (ACUM) in a patient with infertility and chronic pelvic pain. In addition, we summarize the literature to better characterize ACUM diagnosis and management. Design: A comprehensive literature search using the PubMed database was performed through April 2023. Historical ACUM diagnostic criteria were applied as inclusion criteria. Descriptive statistics and statistical evaluation were reported. Results: A 31-year-old nulligravid woman presented with chronic pelvic pain, dysmenorrhea, primary infertility, and history of endometriosis. Three-dimensional ultrasonography identified an ACUM and laparoscopic excision provided complete resolution of symptoms. Subsequently, she conceived without assistance twice with uncomplicated vaginal deliveries. A total of 154 articles were identified, 34 papers met inclusion criteria and were individually reviewed, consisting of 70 reported cases. The most common presenting complaints were dysmenorrhea (81.4%), chronic pelvic/abdominal pain (54.1%), and refractory pain (34.3%). Diagnostic imaging included magnetic resonance imaging (62.9%) and transvaginal ultrasound (55.7%). Management included resection via laparoscopy (75.7%) or laparotomy (18.6%), or hysterectomy (5.7%). Of cases with reported outcomes, 90.7% had complete relief of symptoms after surgery. Conclusion: ACUM often presents with dysmenorrhea, chronic pelvic pain, or abdominal pain and is identifiable on magnetic resonance imaging as a hyperenhancing mass. Three-dimensional transvaginal ultrasound can also accurately identify ACUM. A total of 90.7% of patients had complete relief of symptoms after intervention. It is important to identify ACUM early to relieve pain and reduce unnecessary interventions. Like our patient, other reports have demonstrated concomitant infertility and endometriosis. However, further investigation is needed to explore the association between infertility and ACUM.

Antenatal Three-Dimensional Printing for Ex Utero Intrapartum Treatment Procedures.

BACKGROUND: Prenatal ultrasonography allows for timely identification of fetal abnormalities that can have an effect on securing the neonatal airway at delivery. We illustrate the role of antenatal three-dimensional printing in cases with fetal airway obstruction. CASE: We present two cases that highlight the utility of a three-dimensional printing technique to aid in ex utero intrapartum treatment procedures during cesarean delivery. CONCLUSION: Three-dimensional printing plays a complementary role to standard imaging options in optimizing presurgical planning, prenatal parental counseling, personalized patient care, and education of the multidisciplinary team in cases of fetal congenital airway obstruction.

Integrating Microarrays into Routine Prenatal Diagnosis: Determinants of Decision Making.

OBJECTIVES: The explosion in genetic technologies, including array comparative genomic hybridization (aCGH), has increased the complexity of genetic counseling. We now offer chorionic villus sampling (CVS) and aCGH to all first-trimester patients, as this allows the prenatal diagnosis of an additional 1% of anomalies not otherwise detectable and can detect genetic copy number variants at a much higher resolution than conventional cytogenetics. Here, we explored some of the determinants of how patients are deciding to use or not use this new technology and evaluate risk-benefit analyses for that decision. METHODS: This is a retrospective case-control study of singleton and multiples pregnancies at our center. Those having aCGH testing along with CVS were defined as 'testers' and those who declined aCGH but had the CVS were 'nontesters'. RESULTS: Demographic data of 181 educated women who chose CVS were compared. Among those carrying singletons (n = 144), older women, defined as over 35 years of age (or 'advanced maternal age'; AMA), were more likely to choose the aCGH than younger women. Further, women who had a prior history of genetic testing and who wanted to know the gender of the fetus were more likely to choose the aCGH test. In women carrying multiples (n = 37), AMA ceases to be a predictor of choice. Having had prior genetic counseling remains a strong predictor for choosing aCGH, as does wanting to know the gender of the fetus. Neither prior abortions nor having prior children were significant for women carrying singletons or multiples. CONCLUSION: Offering pregnant couples an individualized choice regarding aCGH seems an appropriate approach. There are discrete patterns associated with the choice of taking the aCGH that varied depending on whether the patient was carrying a singleton or multiples.

Cerclage retention versus removal following preterm premature rupture of membranes and association with amniotic fluid markers.

OBJECTIVE: To evaluate whether amniotic fluid markers can aid the decision of whether to retain or remove a cervical cerclage after preterm premature rupture of membranes (PPROM). METHODS: A retrospective cohort study included pregnancies involving PPROM after diagnostic amniocentesis and cerclage placement. Cerclage was retained for more than 12 hours after PPROM in the study group (n=18); the comparison group comprised women who underwent immediate cerclage removal after PPROM (n=22). Analyses were performed using concentrations of interleukin (IL)-6, glucose, and white blood cells (WBCs) in the amniotic fluid to measure relationships with adverse outcomes. RESULTS: The latency period from PPROM to delivery was significantly shorter in the group that underwent immediate cerclage removal (P<0.005). Latency periods of more than 48 hours (P<0.001) and more than 7 days (P<0.01), and chorioamnionitis (P<0.05) were associated with cerclage retention. Neonatal outcomes were not significantly different between the study group and the comparison group. However, elevated IL-6 levels were associated with cumulative neonatal morbidity (P<0.05). Low IL-6 (P<0.001) and WBC (P<0.05) levels were significantly associated with a latency period of more than 7 days. CONCLUSION: Amniotic fluid levels of IL-6 and WBCs may be of clinical value for individualizing the management of patients with PPROM after cerclage.

Amniotic fluid inflammation with negative culture and outcome after cervical cerclage.

OBJECTIVE: To determine whether amniotic fluid (AF) inflammation, in the absence of infection, is associated with adverse pregnancy outcomes in nonelective cervical cerclage patients. METHODS: A retrospective case-control study was carried out. The patient population included 82 singleton pregnancies with negative AF cultures. The variables used to define AF inflammation were white blood cell count (WBC) >50 cell/mm(3), glucose <14 mg/dl or interleukin-6 (IL-6) >11.3 ng/ml. The study group consisted of cases with intra-amniotic inflammation. Sub-analysis was performed for the groups in which IL-6 concentrations were measured. Adverse outcomes were evaluated with variables such as gestational age at delivery, interval from cerclage to delivery, chorioamnionitis and cumulative neonatal morbidity. RESULTS: Elevated AF WBC was correlated with severe and extreme preterm delivery (p < 0.05). Decreased AF glucose was associated with histological chorioamnionitis and a decreased cerclage to delivery interval (p < 0.05). Elevated AF IL-6 correlated significantly with decreased gestational age at delivery (p < 0.012) and decreased cerclage to delivery interval (p < 0.001). Elevated IL-6 concentrations were associated with severe, extreme preterm delivery (p < 0.001) and neonatal death (p < 0.001). CONCLUSION: Elevated AF IL-6, elevated WBC and low AF glucose, in the absence of a positive AF culture, are significantly associated with adverse pregnancy outcomes in patients undergoing nonelective cerclage.

Male gender significantly increases risk of oxidative stress related congenital anomalies in the non-diabetic population.

OBJECTIVE: Oxidative stress (OS) is an important mechanism of teratogenesis. Recent work suggests increased OS in males. We evaluated whether male gender increased the risk of cyanotic congenital heart defects (CCHD) whose development is linked to OS and other common congenital anomalies (CA) in non-diabetic pregnancies. METHODS: CDC-National Center for Health Statistics data for 19 states in 2006 were reviewed. CCHD, anencephaly, spina bifida, congenial diaphragmatic hernia (CDH), omphalocele, gastroschisis, limb defects, cleft lip with or without cleft palate (CL/P) and isolated cleft palate were evaluated. Adjusted odds ratio (OR) (95% CI) were calculated for CA in males with females as the reference group. RESULTS: Of 1,194, 581, cases analyzed after exclusions, 3037 (0.25%) had major CA. Males had elevated adjusted OR (95% CI) for CCHD: 1.198 (1.027, 1.397), CDH: 1.487 (1.078, 2.051), and CL/P: 1.431 (1.24, 1.651). There was a significant interaction between cigarette use and (male) fetal gender and also with maternal age in the CL/P group. CONCLUSIONS: In non-diabetic pregnancies, male gender appears to be an independent risk factor for some types of CA believed to be associated with OS. Cigarette smoking, a well recognized source of OS only increased the risk of CL/P in males.

Evolución a largo plazo del infarto de ventrículo derecho / Long term follow-up of right ventricular infarction

Se estudia la evolución a largo plazo de 36 supervivientes a la fase hospitalaria de un infarto posteroinferior extendido al ventrículo derecho. El grupo lo constituyeron 7 mujeres y 29 varones con una edad media de 55 años. El tiempo de seguimiento fué de 39 meses como promedio. Se analizó la evolución en la fase aguda y se correlacionó con la mortalidad, complicaciones y capacidad funcional en la evolución a largo plazo. La mortalidad fué del 5.5%. Cinco pacientes desarrollarón un nuevo infarto de miocardio (16%). Ningún enfermo tuvo manifestación de insuficiencia cardíaca derecha durante su evolución tardía y en un solo caso se detectó insuficiencia tricuspídea. La mayor parte de los pacientes estaban en clase funcional I (55.5%) el 36.6% en clase II y el 8.3% en clase III. Ser concluye que la mortalidad a largo plazo de los pacientes con infarto del ventrículo derecho no es mayor que la de otros enfermos con infarto de miocardio; que la gran mayoría evolucionan favorablemente en cuanto a capacidad funcional y cuando no es así habitualmente es debido a una mala función ventricular izquierda secundaria a la gravedad y extensión de las lesiones coronarias; el subgrupo de pacientes con grave disfunción ventricular derecha durante la fase aguda del infarto no tuvo pronóstico peor a largo plazo