Outcome of twin-to-twin transfusion syndrome in monochorionic monoamniotic twin pregnancy: systematic review and meta-analysis.

OBJECTIVES: To explore the outcome of monochorionic monoamniotic (MCMA) twin pregnancies affected by twin-to-twin transfusion syndrome (TTTS). METHODS: MEDLINE and EMBASE databases were searched for studies reporting the outcome of MCMA twin pregnancies complicated by TTTS. The primary outcome was intrauterine death (IUD); secondary outcomes were miscarriage, single IUD, double IUD, neonatal death (NND), perinatal death (PND), survival of at least one twin, survival of both twins and preterm birth (PTB) before 32 weeks' gestation. Outcomes were assessed in MCMA twins affected by TTTS not undergoing intervention and in those treated with amniodrainage, laser therapy or cord occlusion. Subgroup analysis was performed including cases diagnosed before 24 weeks. Random-effects meta-analysis of proportions was used to analyze the data. RESULTS: Fifteen cohort studies, including 888 MCMA twin pregnancies, of which 44 were affected by TTTS, were included in the review. There was no randomized trial comparing the different management options in MCMA twin pregnancies complicated by TTTS. In cases not undergoing intervention, miscarriage occurred in 11.0% of fetuses, while the incidence of IUD, NND and PND was 25.2%, 12.2% and 31.2%, respectively. PTB complicated 50.5% of these pregnancies. In cases treated by laser surgery, the incidence of miscarriage, IUD, NND and PND was 19.6%, 27.4%, 7.4% and 35.9%, respectively, and the incidence of PTB before 32 weeks' gestation was 64.9%. In cases treated with amniodrainage, the incidence of IUD, NND and PND was 31.3%, 13.5% and 45.7% respectively, and PTB complicated 76.2% of these pregnancies. Analysis of cases undergoing cord occlusion was affected by the very small number of included cases. Miscarriage occurred in 19.2%, while there was no case of IUD or NND of the surviving twin. PTB before 32 weeks occurred in 50.0% of these cases. CONCLUSIONS: MCMA twin pregnancies complicated by TTTS are at high risk of perinatal mortality and PTB. Further studies are needed in order to elucidate the optimal type of prenatal treatment in these pregnancies. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

First trimester fetal heart rate as a predictor of newborn sex.

OBJECTIVE: To predict the sex of newborns using first trimester fetal heart rate (FHR). METHODS: This was a retrospective review of medical records and ultrasounds performed between 8 and 13 weeks of gestation. Continuous variables were compared using Student's t-tests while categorical variables were compared using Chi-square test. RESULTS: We found no significant differences between 332 (50.7%) female and 323 (49.3%) male FHRs during the first trimester. The mean FHR for female fetuses was 167.0 ± 9.1 bpm and for male fetuses 167.3 ± 10.1 bpm (p = 0.62). There was no significant difference in crown rump length between female and male fetuses (4.01 ± 1.7 versus 3.98 ± 1.7 cm; p = 0.78) or in gestational age at birth (38.01 ± 2.1 versus 38.08 ± 2.1 weeks; p = 0.67). The males were significantly heavier than females (3305.3 ± 568.3 versus 3127.5 ± 579.8 g; p < 0.0001) but there were no differences in the proportion of small for gestational age (SGA), average for gestational age (AGA) and large for gestational age (LGA) infants. CONCLUSIONS: We found no significant difference between the female and male FHR during the first trimester in contrast to the prevailing lay view of females having a faster FHR. The only statistically significant difference was that males weighed more than female newborns.

Plasma beta-endorphin and beta-lipotropin in the human fetus at delivery: correlation with arterial pH and pO2.

Beta-endorphin-like immunoactivity was measured in the umbilical cord plasma of 45 term human fetuses. Mean concentration was 91 +/- 16 (SEM) pg/ml,an the normal adult level of 30.7 +/- 2.7 pg/ml. This immunoactivity was further characterized in 10 cases by Sephadex G-50 chromatography to separate beta-endorphin from beta-lipotropin (beta-LPH). Mean beta-endorphin and beta-LPH concentrations were 57 +/- 12.8 and 455 +/- 101 pg/ml, respectively. Both were higher (P less than 0.01) than the mean beta-endorphin and beta-LPH concentrations reported in the adult. The mean molar beta-endorphin to beta-LPH ratio was 0.35 in the fetus and 0.36 in the adult. In 17 fetuses whose umbilical arterial and venous concentrations were measured separately, mean beta-endorphin-like immunoactivity was higher in the artery than in the vein. A highly significant negative correlation (r = -0.831; P less than 0.001) was present between umbilical arteiral pH and beta-endorphin-like immunoactivity. A negative correlation (r = -0.611; P less than 0.005) with arterial pO2 was also noted. We conclude that high levels of beta-endorphin-like immunoactivity, composed of both beta-endorphin and beta-LPH, circulate in the human fetus at term, and that hypoxia and secondary acidosis may be major stimuli to the release of these peptides.

Use of glycosylated hemoglobin as a screen for macrosomia in gestational diabetes.

Glycosylated hemoglobin and blood sugar levels in the fasting state and two hours after oral 100 g glucose load were measured in 180 patients. Glycosylated hemoglobin was measured by cation exchange column chromatography, and blood sugar was measured by hexokinase reaction. Patients with an elevated postprandial and/or fasting blood sugar level (positive screen) subsequently underwent three-hour glucose tolerance test. The mean value of glycosylated hemoglobin in patients with a negative screen and normal hemoglobin was 6.17 +/- 0.61%; and the value for glycosylated hemoglobin in patients with class A diabetes and normal hemoglobin electrophoresis was 6.85 +/- 0.73% (P less than .001). A glycosylated hemoglobin value greater than 6.78 (mean + 1 SD) was considered elevated. Glycosylated hemoglobin values were elevated in 21 of 33 patients with gestational diabetes and in 27 of 147 patients with normal blood sugar levels. The sensitivity and specificity of glycosylated hemoglobin for the diagnosis of gestational diabetes were 63.6 and 81.6%, respectively. Fifty percent of patients with an initially elevated glycosylated hemoglobin value delivered macrosomic infants, whereas no patient with a normal glycosylated hemoglobin value had a macrosomic infant. An elevated glycosylated hemoglobin value may alert the obstetrician of a potentially elevated mean blood sugar level and may warrant aggressive management of gestational diabetes.

Early detection of caudal regression syndrome with transvaginal scanning.

High-resolution transvaginal ultrasonography may recognize structures in the first- and early second-trimester fetus. In a patient with pregestational diabetes, caudal regression syndrome in the fetus was diagnosed using transvaginal ultrasonography. At 9 weeks of gestation, a shortening of the crown-rump length and a protuberance of the lower spine suggested caudal regression syndrome. By 17 weeks of gestation, the diagnosis was made with certainty. The transvaginal approach has changed the role of first-trimester ultrasound in the diabetic pregnancy. We suggest that transvaginal ultrasonography be used for purposes of accurate dating and for early detection of diabetic embryopathy, particularly in patients with poor periconceptional glycemic control.

An unusual complication in a gravida with factor IX deficiency: case report with review of the literature.

Factor IX deficiency (hemophilia B, Christmas disease) is an X-linked recessive coagulation disorder. It occurs in one out of every 25,000-30,000 male births and requires even rarer genetic circumstances for phenotypic expression in females. We report the occurrence of a large, late-trimester subchorionic hematoma in a gravida with factor IX deficiency and with laboratory evidence of consumptive coagulopathy during treatment. The patient was managed conservatively and had a successful outcome at term. The only four reported cases of antepartum management of factor IX deficiency in the English literature are reviewed.

Appearance of neuropeptides and NADPH-diaphorase during development of the enteropancreatic innervation.

Pancreatic ganglia are formed by neural crest-derived precursors, are innervated by enteric neurons, and contain neuropeptides. In addition, the enzyme NADPH-diaphorase is located in a subset of enteric and pancreatic neurons. The expression of neural markers (GAP-43 and NC-1), neurotransmitter-related markers (including neuropeptide Y (NPY), vasoactive intestinal peptide (VIP), gastrin-releasing peptide (GRP), galanin (GAL), dopamine beta hydroxylase (DBH), substance P (SP), calcitonin gene-related peptide (CGRP)), and NADPH-diaphorase was studied in the fetal and neonatal rat gut and pancreas (E12-P28) in situ and in vitro. NC-1, GAP-43 and DBH-immunoreactive cells were found in the primordial stomach on day E12, and in the pancreas on day E13, along with NPY in endocrine cells. Pancreatic NPY-immunoreactive neurons were detected by day E18. CGRP was seen in the foregut at day E12 but not in the pancreas until day E14. Other neuropeptides (SP, GAL, GRP and VIP) all appeared in the foregut earlier than in the pancreas. NADPH-diaphorase activity was first found in situ in foregut neurons on day E13, and in the pancreas on day E14, but seen in explants a day earlier. These observations show that development of neurons occurs earlier in the gut than in the pancreas, and that NADPH-diaphorase activity appears earlier than the immunoreactivities of the neuropeptides.

Subchorionic hematoma: a review.

A review of the English literature on subchorionic hematoma (SCH) is presented. Fourteen studies are reviewed. The incidence of SCH varied greatly among studies from 4 to 48 per cent. Small SCH tend to be more common in the first trimester and appear to pose no added risk to the ongoing pregnancy. Conversely, SCH in the second trimester often are larger and may be associated with an increased risk of preterm delivery. The etiology of these hematomas remains unclear. Pathological changes that might contribute to their formation are reviewed. Larger studies with controls, including data on the incidence of SCH in a population of normal obstetric patients are needed.

Laparoscopic cholecystectomy during pregnancy: a case series and review of the literature.

This study was conducted to evaluate the role of antepartum laparoscopic cholecystectomy (LC). Patients who underwent LC were identified from a hospital database with the use of CPT/ICD codes. Of 2093 cases performed at a major center (October 1991 to November 1997), only six were performed during pregnancy. On reviewing the English literature, gestational age at surgery and delivery and outcome of delivery were provided in only 69 of 105 patients (33 papers with 1-10 cases) and we tabulated different variables from the cases in this review. In this series, two patients who had LC in the first trimester underwent elective termination of pregnancy. Of the seven published cases of first trimester LC followed to delivery, one had preterm delivery. First trimester open cholecystectomy (OC) has a 12 percent spontaneous abortion rate. The four patients who had second trimester LC had normal deliveries at term. Of the 43 published cases of second trimester LC followed to delivery, 39 ended in uncomplicated, full-term deliveries. Three of four second trimester cases at one institution had spontaneous abortions. None of our patients underwent LC in the third trimester. Of the 12 published cases of third trimester LC followed to delivery, one had preterm delivery. Third trimester OC is reported to have a 40 percent rate of preterm delivery. There were no intraoperative cholangiograms (IOC), prophylactic or postoperative use of tocolytics, or intraoperative fetal monitoring in our series. We added six cases of LC during pregnancy to the previously reported 105 cases. The successful outcome in all trimesters suggests that LC is a safe procedure throughout pregnancy; however, surgery in the second trimester is preferable. Compared with OC, there is a decreased risk of spontaneous abortion in the first trimester and preterm labor in the third trimester.

Perinatal mortality in diabetic patients undergoing antepartum fetal evaluation: a case-control study.

OBJECTIVE: To identify changing trends, if any, of fetal loss in diabetic patients undergoing antepartum fetal evaluation in a case-control study. METHODS: Fetal assessment (non-stress test and/or biophysical profile) logbooks from January 1981 to June 1998 were reviewed and the patients with diabetes were identified. The study group comprised patients with pregnancy loss. Each case was matched by year of delivery and class of diabetes with four randomly selected controls with no pregnancy loss. All patients in both groups were at > 26 weeks' gestation. RESULTS: Thirteen stillbirths and four neonatal deaths occurred in 1,935 diabetic patients who underwent fetal evaluation. There was no significant difference in age, race, gravidity, parity, clinic or private service, or the type of delivery in the two groups. Losses were more likely (p < 0.001) to occur before 32 weeks, with birth weights < 2,500 g, with a greater time interval from their last fetal evaluation, with poor glycemic control and with congenital malformations (six of seven occurred before 1990). In this study, perinatal losses were associated with non-compliance and other associated problems in the mother. Overall perinatal mortality in these patients was 17 per 1935 and corrected 11 per 1935 or 5.6 per 1,000. CONCLUSION: In the 1980s suboptimal glycemic control with major fetal malformations emerged as the major contributory factor to perinatal loss and, in the 1990s, this was associated medical problems. With a better awareness of the adverse effect of suboptimal glycemic control at the time of organogenesis and advances in fetal diagnosis and evaluation, fetal loss due to diabetes has become a rarity. Patients with associated medical problems and those at risk for abruptio placentae should be managed more aggressively.

Amniotic fluid prolactin levels in rhesus isoimmunized patients.

The concentration of prolactin in the amniotic fluid (AFPRL) was measured in 75 samples obtained in the third trimester of 14 isoimmunized women. There was a uniform decline in prolactin levels with advancing gestation in each pregnancy (r = -0.89 to -0.99). The decline in AFPRL was similar in uncomplicated pregnancies. AFPRL levels were not predictive of umbilical cord hemoglobin or bilirubin levels and amniotic fluid lecithin/sphingomyelin ratio.

Tamoxifen-induced growth of leiomyomas. A case report.

BACKGROUND: Tamoxifen, a nonsteroidal estrogen agonist-antagonist, is used in the treatment of breast cancer. CASE: A postmenopausal woman, aged 73, while being treated with Tamoxifen, developed continuous growth of her myomatous uterus, became symptomatic and required surgery. CONCLUSION: Tamoxifen at a dose of 40 mg/d has been associated with endometrial carcinoma. The growth of myomas seen with Tamoxifen in this patient seems to be a result of its direct agonist properties.

Cerebral abscess and thrombophilia in pregnancy. A case report.

BACKGROUND: Cerebral abscess in pregnancy is a rare event, with the etiology not well described. We present such a case in association with genetic thrombophilia. CASE: A 36-year-old primigravida with a prior history of bilateral popliteal vein thrombosis and pulmonary embolism presented in early gestation with right hemiparesis, aphasia, disseminated intravascular coagulation and a space-occupying lesion in the left temporal lobe. Stereotactic biopsy confirmed the presence of an abscess. The patient also had a homozygous methylene tetrahydrofolate reductase mutation (C677T), protein S deficiency and lupus anticoagulant, all of which possibly contributed to the thrombosis, infarct, infection and abscess. She was successfully treated with low-molecular-weight heparin and antibiotics and had a term vaginal delivery. CONCLUSION: Recently genetic thrombophilia was reported in association with various complications of pregnancy, but it has never before been described as occurring with a cerebral abscess.

Alpha-fetoprotein in diabetic pregnancy. A reassessment.

We correlated glycosylated hemoglobin (HbA1) with maternal serum alpha-fetoprotein (MSAFP) in 92 and amniotic fluid AFP (AFAFP) in 27 patients with pregestational and gestational diabetes. MSAFP and AFAFP were measured between 15 and 20 weeks and correlated with HbA1. In group 1, HbA1 was measured at < or = 12 weeks' gestation; in group 2, it was measured 0-6 weeks before MSAFP measurement; and in group 3, it was measured within 6 weeks after MSAFP. Mean MSAFP was 1.02 +/- 0.77 multiples of the median (MOM) (+/- SD) in all diabetics, 1.1 +/- 0.93 MOM in gestational diabetics and 0.89 +/- 0.33 MOM in pregestational diabetics (P = NS). There was no correlation between MSAFP and HbA1 in groups 1-3. Patients with HbA1 > 9 g% had a mean MSAFP of 0.84 MOM as compared to 0.85 MOM in those with HbA1 < 9 g% (P = NS). AFAFP values were within normal limits even in patients with HbA1 > 9 g% in early pregnancy (n = 8). No significant decrease in MSAFP was seen in pregestational diabetics, and no correlation was seen with HbA1 levels. AFAFP levels were unchanged in diabetics.

Pregnancy complicated by maternal spina bifida. A report of two cases.

Pregnancy occurred in two women who had undergone corrective surgery for meningomyelocele. Both women had urinary incontinence leading to urinary tract infections and, in one, to vulvitis urinosa. There is limited literature on maternal meningomyelocele and its complications.

Fetal faciocervical teratoma with anemia and thrombocytopenia. A case report.

A massive teratoma in the faciocervical region was found in a fetus at 21 weeks, with laboratory evidence of anemia and thrombocytopenia. Vaginal delivery was achieved by cardiocentesis followed by Laminaria tent insertion, dilation and evacuation.

Transcranial Doppler blood flow measurement during cesarean section in two patients with cerebral vascular disease.

We present two cases of neurovascular disease in pregnancy in which transcranial Doppler was used to assess the status of the cerebral circulation during cesarean section under regional anesthesia. One woman had been found to have moyamoya disease, following a series of transient ischemic attacks during her first pregnancy, which ended in spontaneous abortion. On this occasion she was delivered by cesarean section under slowly-induced epidural anesthesia, using ephedrine to maintain the blood pressure, and transcranial Doppler revealed no change in signal in her left middle cerebral artery. Both mother and baby had an uneventful post natal course. The second case involved a primiparous woman with a large arteriovenous malformation that had been detected following generalized seizures, which were treated with valproic acid. Her cesarean section was conducted under spinal anesthesia, and her blood pressure maintained with ephedrine. Again transcranial Doppler revealed no change in signal in her middle cerebral artery during the procedure. We believe this is a potentially useful technique to monitor the cerebral circulation intraoperatively in the presence of cerebrovascular disease.

Congenital cataract in triplet pregnancy after ivf with frozen embryos: prenatal diagnosis and management.

Unilateral congenital cataract was diagnosed at the 2nd trimester ultrasonography in a triplet pregnancy following in vitro fertilization (with frozen embryos). Congenital cataract could be hereditary or related to metabolic and infectious disorders. To our knowledge this is the first antenatal diagnosis of the disorder in triplets after IVF with frozen embryos.