Acupressure and Acupuncture Use in the Peripartum Period.

Acupuncture is the procedure of inserting fine needles into specific points on the body for therapeutic purposes. Acupuncture and its derivatives (acupressure, moxibustion, electroacupuncture, and transcutaneous electric nerve stimulation on acupoints) are a popular treatment choice in the peripartum period (32 wk' gestation to 14 d postdelivery). There is substantial research evidence supporting acupuncture and its derivatives in the peripartum period. Benefits in the use of acupressure to reduce labor pain intensity and a reduction in the duration of labor with acupressure have been found. There is mixed evidence for the use of both moxibustion and moxibustion with acupuncture for noncephalic presentations and for acupressure for reducing intraoperative nausea. There is limited evidence available on acupuncture use in women with high-risk pregnancies or multifetal gestations.

Treatment of Philadelphia chromosome-positive acute lymphoblastic leukemia in pregnancy.

BCR-ABL inhibitors administered in conjunction with chemotherapy have significantly improved outcomes in Philadelphia chromosome-positive acute lymphoblastic leukemia but, for patients diagnosed during pregnancy, data on risks to the fetus are limited. We report a woman treated with chemotherapy and imatinib mesylate who delivered a healthy baby at 30 weeks, and we discuss available data.

Isolated low-normal amniotic fluid volume in the early third trimester: association with adverse perinatal outcomes.

AIMS: To test if an isolated finding of low-normal amniotic fluid index (AFI) in the early third trimester in low-risk patients is associated with adverse perinatal outcomes. METHODS: Retrospective cohort study with uncomplicated singleton pregnancies that had ultrasound studies between 28.0 and 31.9 weeks' gestation. Two cohorts with AFI 8.0-11.9 cm (low-normal, LN) and AFI 12.0-19.9 cm (mid-normal, MN) were compared. RESULTS: Patients with LN-AFI (n=99) were more likely to have early (<34 weeks) and late (<37 weeks) preterm birth (PTB) (relative risk 4.2 and 2.4, respectively) and a small for gestational age (SGA) infant (relative risk 1.8) than MN-AFI (n=834), corresponding to a higher NICU admission rate (relative risk 2.5). The risk of "spontaneous" PTB (preterm labor and rupture of membranes) did not differ between the cohorts, whereas the risk of "indicated" PTB (maternal or fetal indications) was significantly increased in LN-AFI. The incidence of abnormal antepartum testing, stillbirth, preeclampsia, placental abruption, fetal intolerance to labor, emergency cesarean delivery, umbilical artery pH <7.0, Apgar scores <7 at 5 min, and neonatal death was not increased in patients with LN-AFI. CONCLUSION: Low-normal AFI in the early third trimester increases the risk for subsequent delivery of an SGA infant and indicated PTB.

Maternal obesity-associated disruption of polarized lactate transporter MCT4 expression in human placenta.

Maternal obesity is associated with an increased risk of adverse pregnancy outcomes including stillbirth, and their etiology is thought to be related to placental and fetal hypoxia. In this study, we sought to investigate the levels of lactate in maternal and umbilical cord blood, a well characterized biomarker for hypoxia, and expression of plasma membrane lactate transporter MCT1 and MCT4 in the placental syncytiotrophoblast (STB), which are responsible for lactate uptake and extrusion, respectively, from pregnant women with a diagnosis of obesity following a Cesarean delivery at term. With use of approaches including immunofluorescence staining, Western blot, RT-qPCR and ELISA, our results revealed that in controls the expression of MCT1 was equally observed between basal (fetal-facing, BM) and microvillous (maternal-facing, MVM) membrane of the STB, whereas MCT4 was predominantly expressed in the MVM but barely detected in the BM. However, obese patients demonstrated significant decreased MCT4 abundance in the MVM coupled with concurrent elevated expression in the BM. We also found a linear trend toward decreasing MCT4 expression ratio of MVM to BM with increasing maternal pre-pregnancy BMI. Furthermore, our data showed that the lactate ratios of fetal cord arterial to maternal blood were remarkably reduced in obese samples compared to their normal counterparts. Collectively, these results suggest that the loss of polarization of lactate transporter MCT4 expression in placental STB leading to disruption of unidirectional lactate transport from the fetal to the maternal compartment may constitute part of mechanisms linking maternal obesity and pathogenesis of stillbirth.

A clinical and biological comparison between malignant mixed müllerian tumors and grade 3 endometrioid endometrial carcinomas.

OBJECTIVE: To examine the clinicopathologic features, progression-free interval, and survival of patients with grade 3 endometrioid endometrial cancer (G3 EEC) and malignant mixed müllerian tumors (MMMTs). Akt, epidermal growth factor receptor (EGFR), and HER-2/neu expression in these histologic subtypes was also investigated. Associations between phosphorylated Akt and clinicopathologic features were tested. METHODS: One hundred nineteen women whose conditions were diagnosed with MMMT or G3 EEC from January 1, 1990, to December 31, 2003, met inclusion criteria. Retrospective data review was performed. In addition, Akt and EGFR protein expression was measured in tissue samples using Western blotting and immunohistochemistry. Fluorescence in situ hybridization was used to assay HER-2/neu gene amplification. RESULTS: Fifty-nine patients with MMMT and 60 patients with G3 EEC were identified. Patients with MMMT were older (P = 0.055), more likely to be African American (P = 0.049), have a family history of breast cancer (P = 0.039), have disease involving the uterine cervix (P = 0.007), and experience postoperative complications (P = 0.012). Patients with MMMT had a significantly shorter progression-free interval (23 vs 57 months, P = 0.001) and survival (55 vs 92 months, P = 0.001) than patients with G3 EEC.Grade 3 EEC and MMMT have significantly higher phospho-Akt levels than grade 1 EEC and normal controls. Phospho-Akt was associated with depth of myometrial invasion (r = 0.46, P = 0.05), but not with stage, lymph-vascular space invasion, or tumor size. The mesenchymal component of MMMT preferentially demonstrated EGFR expression relative to the epithelial component (45% vs 13%, P = 0.06). HER-2/neu amplification was observed in 1 of 37 samples. CONCLUSIONS: Improved therapy is warranted for both poorly differentiated EEC and MMMT. Recognition of similarities and differences between MMMT and other high-grade histologic types of uterine cancer may provide rationale for new treatment approaches possibly incorporating targeted biological therapies.

Liver lacerations as a complication of CPR during pregnancy.

AIM: Cardiac arrest in peripartum patients is a rare but devastating event; reported rates in the literature range from 0.019% to 0.0085%. In the general population, a well-described complication of cardiopulmonary resuscitation (CPR), liver laceration and injury, is reported at a rate of between 0.5-2.9% after CPR. Liver laceration rate among peripartum patients receiving CPR has not been well-studied. We sought to find the rate of liver lacerations in the peripartum population associated with CPR, with the hypothesis that the rate would be higher than in the general population. METHODS: We identified pregnancies complicated by cardiac arrest by performing a retrospective medical record review from 2011 to 2016 at a single tertiary referral hospital. We then compared the rate of liver lacerations in this group to the rate in the general population as found in the literature. RESULTS: Eleven of 9408 women in the peripartum period suffered cardiac arrest. Return of spontaneous circulation occurred in seven of eleven (64%) women. Three of these seven women suffered clinically significant liver laceration (43%). Overall mortality rate among women suffering cardiac arrest was 82% (9/11).Even after return of spontaneous circulation, the mortality rate was 72%(5/7) including two of three women suffering liver laceration. CONCLUSIONS: Based on a small retrospective study, liver lacerations requiring intervention occurred in 43% of gravidas patients that survived CPR, and is significantly higher than published rates (0.6-2.1%) for the general patient population. Further studies are indicated to determine the incidence of liver injury after peripartum CPR.

Do vaginal birth after cesarean outcomes differ based on hospital setting?

OBJECTIVE: The objective of the study was to test the null hypothesis that outcomes of vaginal birth after cesarean (VBAC) do not differ on the basis of the hospital setting. STUDY DESIGN: The study was a retrospective cohort study of women who were offered VBAC in 17 hospitals from 1996 to 2000. VBAC attempts occurring in hospitals with and without obstetrics-gynecology residency programs were compared, as were outcomes from university and community hospitals. Bivariate and multivariate logistic regression analyses assessed the association between hospital setting and VBAC outcomes. RESULTS: Of 25,065 women with 1 or more prior cesareans, the VBAC attempt rate was 56.1% at hospitals with obstetrics-gynecology residencies, 51.3% at hospitals without obstetrics-gynecology residencies, 61% at university hospitals, and 50.4% at community hospitals. The occurrence of failed VBAC, blood transfusion, or composite adverse outcome did not differ by hospital setting. There was a significant increase in the uterine rupture rate at community (1.2%) vs university hospitals (0.6%), but the absolute risk remained low. CONCLUSION: The rate of VBAC-associated complications is low, independent of hospital setting.

Interobserver variability with the interpretation of thyroid FNA specimens showing predominantly Hürthle cells.

Fine-needle aspiration (FNA) is used for the diagnosis and triaging of thyroid lesions. Recently, it has been shown that the pathologic interpretation of selected thyroid specimens can show a high degree of interobserver variability (IV). Because Hürthle cells may be seen in neoplastic and nonneoplastic disease, we investigated whether pathologists consistently interpret FNA specimens from these lesions. In the present study, 22 FNA specimens that showed Hürthle cells as the predominant cell type were reviewed by 7 pathologists. Cytologic features were assessed semiquantitatively. IV was calculated, and individual case diagnoses were compared with cytologic features. IV was high before diagnoses were collapsed into like diagnoses and triage recommendations (k = 0.17, 0.44, and 0.51, respectively). Overall cellularity, number of Hürthle cells, and number of lymphocytes all correlated with collapsed diagnostic agreement, and the number of air-dried rapid Romanowsky-stained slides, overall cellularity, number of Hürthle cells, and number of lymphocytes all correlated with collapsed triage recommendations.

Evaluation of polymerase chain reaction for group B streptococcus detection using an improved culture method.

OBJECTIVE: The administration of antibiotic prophylaxis to laboring women who harbor Group B streptococci (GBS) depends on identification of carriers. We sought to evaluate the diagnostic accuracy of real-time polymerase chain reaction (PCR) for detection of GBS using a more stringent culture method. METHODS: Two swabs were used simultaneously to obtain rectovaginal GBS samples from consenting women. One swab was analyzed using a stringent, validated culture technology, which included direct plating onto selective agar and inoculation of a selective broth. The other swab was used for a commercial real-time PCR assay, which uses amplification to detect the presence of the cfb gene sequence of GBS DNA. We calculated the assay accuracy using sensitivity and specificity. RESULTS: A total of 233 samples were available. Both the culture and PCR methods were positive for 59 and negative for 157 patients. The culture method was positive and PCR was negative in 9 patients. The culture was negative and the PCR positive for 8 patients. The sensitivity of the PCR assay was 86.8% and specificity was 95.2%. The positive predictive value was 88.1% and the negative predictive value was 94.6%. CONCLUSION: Although a rapid PCR assay may be useful to determine GBS status in the urgent intrapartum setting, the false-negative rate of 13.2% for the real-time PCR assay prohibits its use for standard GBS screening in the office.

The cytologic diagnosis of gangliocytic paraganglioma: a case report.

Gangliocytic paragangliomas are rare tumors primarily found in the duodenum. We report a case of a woman who presented with a retroperitoneal lymph node involved by metastatic gangliocytic paraganglioma. Subsequently, fine-needle aspiration (FNA) cytology was used to identify the primary duodenal gangliocytic paraganglioma. The smears of the aspirate material were highly cellular and contained a dominant population of epithelioid cells, a second population of ganglion cells and a third population of small, bland spindled cells. To our knowledge, the cytologic features of gangliocytic paraganglioma have not previously been documented.

Severe uropathy and normal amniotic fluid volume in a male fetus: sonographic surveillance leading to the diagnosis of megacystis-microcolon-intestinal hypoperistalsis syndrome.

The widespread use of sonography as a screening tool for fetal anomalies has facilitated prenatal detection of several fetal conditions characterized by urinary tract dilatation. These conditions are more common in male fetuses and are generally a result of an anatomic defect causing obstruction along the urinary tract system. Although the prognosis of these conditions largely depends on the specific anomaly, several poor prognostic factors have been described. These factors include detection at an early gestational age, bilateral marked dilatation, a persistently obstructed bladder, oligohydramnios causing pulmonary hypoplasia, and the presence of associated fetal or chromosomal anomalies. We report a case in which a male fetus at 14 weeks' gestation had a diagnosis of rapidly progressing bilateral hydronephrosis, massive bladder dilatation, hydroureter, and a surprisingly normal amniotic fluid volume. Serial sonographic surveillance assisted us in obtaining the correct diagnosis, which was important for adequately consulting the patient regarding the fetal prognosis in the affected index pregnancy as well as the likelihood of recurrence in future gestations.

A case of lymphomatoid papulosis with prominent myxoid change resembling a mesenchymal neoplasm.

Lymphomatoid papulosis is a chronic recurrent eruption of self-regressing papules and nodules. Histologically this disorder is characterized by large atypical lymphoid cells resembling Reed-Sternberg (RS) cells that are set in a background of a mixed inflammatory infiltrate. Depending on the architecture of the infiltrate and the percentage of atypical cells, the histologic appearance is subclassified as type A, B, or C. The different histologic patterns do not seem to correlate with distinct clinical appearances. We report a case of lymphomatoid papulosis with unusual histologic features affecting a 14-year-old girl. The presence of anaplastic cells in a background of myxoid stroma closely resembled a sarcoma on histologic examination.