Maternal morbidity after maternal-fetal surgery.

OBJECTIVE: There is a paucity of published data on the maternal risks of fetal surgical interventions. We analyzed maternal morbidity and mortality that were associated with different types of fetal intervention (open hysterotomy, various endoscopic procedures and percutaneous techniques) to quantify this risk. STUDY DESIGN: We performed a retrospective evaluation of a continuous series of 187 cases that had been performed between July 1989 and May 2003 at the Fetal Treatment Center, a highly specialized interdisciplinary center for fetal surgery at the University of California, San Francisco. The primary outcome was the frequency of maternal morbidity for open, endoscopic, and percutaneous procedures to access the fetus. RESULTS: There were 187 pregnant women with confirmed major fetal malformations who were candidates for intrauterine fetal intervention. Maternal-fetal surgery was performed in 87 cases by open hysterotomy, in 69 cases by endoscopic procedures, and in 31 cases by percutaneous techniques. There were no maternal deaths, but significant short-term morbidity was observed. There were no significant differences in the incidence of premature rupture of membranes, pulmonary edema, placental abruption, postoperative vaginal bleeding, preterm delivery, or interval from maternal-fetal surgery to delivery between endoscopic procedures and open surgery. Complications were significantly less in the percutaneous ultrasound-guided procedures. Endoscopic procedures, even with a laparotomy, showed statistically significantly less morbidity compared with the open hysterotomy group regarding cesarean delivery as delivery mode (94.8% vs 58.8%; P < .001), requirement for intensive care unit stay (1.4% vs 26.4%; P < .001), length of hospital stay (7.9 vs 11.9 days; P = .001), and requirement for blood transfusions (2.9% vs 12.6%; P = .022). Chorion-amnion membrane separation (64.7% vs 20.3%; P < .001) was seen more often in the endoscopy group. CONCLUSION: Short-term morbidities include increased rates of cesarean birth, treatment in intensive care, prolonged hospitalization, and blood transfusion, all of which were more common with hysterotomy compared with other techniques. Maternal-fetal surgery can be performed without maternal death. Results from this study provide helpful data for counseling prospective patients.

Post-partum cerebral angiopathy: repetitive TCD, MRI, MRA, and EEG examinations.

We report of a woman with post-partum cerebral angiopathy (PCA), in whom we repetitively performed transcranial Doppler sonography (TCD), MR imaging (MRI), and MR angiography (MRA) to evaluate the underlying pathophysiology. A 31-year-old woman, Gemini pregnant, complained of severe throbbing frontal headache four days after an uneventful delivery by Cesarean section. Blurred vision occurred eight days after delivery, followed by three generalized tonic-clonic seizures. Neurological examination revealed a somnolent woman without focal neurological deficits. At the day of the seizures increased flow velocities and disturbed flow were observed in the right posterior and anterior cerebral artery on transcranial Doppler (TCD). MRI showed infra- and supratentorial patchy hyperintensities in T2-weighted images and in the FLAIR sequence. Diffusion-weighted imaging revealed corresponding multi-focal hyperintense areas indicating increased diffusion and MRA showed a diffuse multisegmental narrowing of all pial arteries. MRI at day 10 was completely normal, but MRA still revealed vascular narrowing in the right posterior cerebral artery. General slight flow accelerations in all basal arteries occurred after 10 days and lasted for three weeks. PCA is apparently associated with a vascular narrowing causing cerebral ischemia with increased diffusion. Later reactive cerebral hyperperfusion is observed. Vascular narrowing and cerebral hyperperfusion still persist after MRI has normalized.

Mastitis nonpuerperalis after nipple piercing: time to act.

OBJECTIVE: To review the literature and discuss problems related to post-piercing breast abscesses. MATERIALS AND METHODS: Retrospective analysis of 10 case reports after Medline and internet search regarding breast abscess after nipple piercing. RESULTS: Nine case reports are published in Medline so far, the first in 1982, but eight within the last 3 years. One abstract of a case report presented at a meeting was found on the internet. Average patient age was 31.2 (15-60) years; 7 female and 3 male. Side of breast infection was 5 right, 4 left, and one both. The interval between piercing and treatment was on the average 20.8 (2-52) weeks, duration of symptoms 1 week to several months. Therapy in 9 patients was antibiotics and in 7 operation. The following major complications were seen: endocarditis, heart valve operation, prosthesis infection, metal foreign body in breast tissue, one reoperation because of recurrent infection, psychological stress because of primary diagnosis of breast cancer in 2 cases. CONCLUSION: The risks in nipple piercing are obviously under-documented and may be as high as 10-20% in the months after the procedure. Healing of the wound channel can take 6-12 months.

Impaired cerebral glucose metabolism in eclampsia: a new finding in two cases.

The pathophysiology of the reversible neurological manifestation in eclamptic women remains unclear. We report on 2 women with eclampsia who were repetitively examined by (1) transcranial Doppler (TCD), (2) magnetic resonance imaging (MRI) including T1- and T2-weighted images, fluid attenuated inversion recovery sequence, dynamic susceptibility-weighted perfusion imaging and magnetic resonance angiography (MRA), and (3) (18)fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET). In both cases repetitive TCD revealed no signs of vasospasm; the same was true for MRA. MRI perfusion imaging showed completely homogenous cerebral blood flow in both cases. In the initial phase T2-weighted images revealed hyperintensities in both patients (predominantly bilateral frontal and parietal in 1 and in the temporo-occipital subcortex and the basal ganglia in the other). FDG-PET showed inhomogeneous glucose metabolism (GM) in both patients. Primary increased glucose utilization in the hyperintense T2-weighted areas as well as an attenuated GM parieto-occipital were observed in the 1st case; a high GM was found bilaterally in the basal ganglia and an attenuated one in the occipital cortex in the 2nd. In both cases MRI, and FDG-PET normalized within 3 weeks. These case reports document an altered cerebral GM in the presence of homogenous perfusion in eclamptic women. The high GM may be explained by a decoupling of cerebral perfusion and GM, possibly indicating an increased neuronal activity. The attenuation of the GM is most probably due to a deafferentation of cortical neurons.