Intrauterine resolution of nonimmune hydrops associated with cytomegalovirus infection.

Intrauterine resolution of a case of nonimmune hydrops fetalis associated with cytomegalovirus infection occurred during conservative antenatal management. Although the etiology for a case of nonimmune hydrops diagnosed antenatally is often obscure, a systematic investigation provided an antenatal diagnosis of cytomegalovirus infection, permitting expectant management and eventual vaginal delivery at term.

Factor VII deficiency and pregnancy.

Hereditary factor VII deficiency is very rare in pregnancy (one in 500,000). However, obstetricians should consider this diagnosis whenever the prothrombin time is prolonged while the activated partial thromboplastin time is normal. The factor VII level increases in normal pregnancy, but the effect of pregnancy upon the factor VII level in deficient individuals is unknown. We report two cases of factor VII deficiency in pregnancy. In both, factor VII levels were 15% or less in the third trimester and were lower postpartum, suggesting that pregnancy does elevate factor VII in deficient individuals as well. Fresh frozen plasma is the treatment of choice. If the level is very low, fresh frozen plasma can be given prophylactically; otherwise, it should be given if blood loss becomes excessive.

Indirect antiglobulin test and anti-D prophylaxis in hereditary persistence of fetal hemoglobin.

The indirect antiglobulin test was used to assess the efficacy of anti-D prophylaxis in two Rh negative women with hereditary persistence of fetal hemoglobin. Saturation of all D sites by passive antibody should be followed by indirect antiglobulin positivity due to excess administered anti-D. In hereditary persistence of fetal hemoglobin, all red cells have fetal hemoglobin making the acid elution test (Kleihauer-Betke smear) to detect feto-maternal hemorrhage useless. The indirect antiglobulin test is recommended in patients with hereditary persistence of fetal hemoglobin.

Glycosylated hemoglobin and protein levels in normal and diabetic pregnancies: relation to birth weight.

Glycosylated hemoglobin and protein were measured in maternal and cord blood of 24 normal, 19 class A, and ten insulin-treated diabetics using an affinity chromatographic technique. Maternal (intrapartum) glycohemoglobin and glycoprotein levels in the diabetics were not significantly different from those in normal controls, suggesting "tight" metabolic control in these patients. Compared with controls, cord blood glycohemoglobin and glycoprotein levels were significantly higher in insulin-treated, but not in class A, diabetics. The birth weight ratio correlated significantly only with maternal glycohemoglobin in insulin-treated diabetics. The results suggest that: even in well-controlled insulin-treated diabetics, the fetuses are hyperglycemic; maternal glycohemoglobin correlates with birth weight in insulin-treated diabetics; maternal glycoprotein determinations cannot be used to predict birth weight; hyperglycemia cannot be the sole determinant of fetal overgrowth in diabetic pregnancies; factors influencing fetal overgrowth in class A and insulin-treated diabetics may be different.

Acid-base determinations in amniotic fluid and blood of normal late pregnancy.

Amniotic fluid (AF) and arterial blood were obtained almost simultaneously from 59 healthy third-trimester pregnant women. Oxygen and carbon dioxide tensions (Po2, Pco2), pH, bicarbonate (Bicarb), total carbon dioxide (TCO2), lactate (L), and pyruvate (P) concentrations were measured. Only AF-Bicarb, AF-TCO2, AF-pH, and AF-P showed a statistically significant correlation, negative, with gestational age. AF-Po2, AF-pH, AF-Bicarb, and AF-TCO2, were lower, and AF-Pco2 was higher than in maternal blood. Amniotic fluid lactate was about 6 times, and AF-P was 2 times higher than maternal blood levels. The latter, the low bicarbonate, and the high Pco2 all contributed to the acidic pH of AF. Amniotic fluid pH was affected by fetal and maternal variables, notably maternal pH. There was no correlation between AF-Po2 and Pao2 (arterial oxygen tension), between AF-Pco2 and Paco2 (arterial carbon dioxide tension), or between AF-L and blood L. AF-Po2, AF-Pco2, and AF-L may correlate better with the intrauterine fetal status than AF-pH. Normal values obtained in this study should be useful as a baseline to monitor changes in the intrauterine environment in abnormal prgenancies.

Isolation of amniotic fluid erythrocytes and their possible use in prenatal diagnosis.

Many of the components of amniotic fluid have been found to be valuable in prenatal diagnosis; however, the presence of erythrocytes is usually considered undesirable. The authors have used buoyant density centrifugation on 96 amniotic fluid specimens from 70 subjects to isolate small numbers of erythrocytes from a majority of these specimens. Through immunofluorescence, these specimens were found to have higher levels of fetal hemoglobin-containing cells than the adult, indicating that the erythrocytes were at least in part fetal in origin. Thus, erythrocytes present in amniotic fluid could also be used in prenatal diagnosis.

The unreliability of amniotic fluid bilirubin measurements in isoimmunized pregnancies in sickle cell disease patients.

Amniotic fluid spectrophotometric analysis for bilirubin (delta optical density [delta OD450], at 450 nm) is used to assess the severity of fetal involvement in isoimmunized pregnancies. Two patients presented with sickle cell anemia and hyperbilirubinemia who also were isoimmunized. The first patient had anti-kell and anti-e antibodies, whereas the second patient had anti-Lewisa and anti-Coltonb antibodies. Delta OD450 was elevated in both patients. The difficulty in interpretation of high delta OD450 in the presence of maternal hyperbilirubinemia is stressed. Sickle cell diseased patients are particularly prone to present with this problem. These patients always have hyperbilirubinemia and a relatively high incidence of irregular antibodies because of the numerous blood transfusions they receive. The management of these two patients is presented with suggestions for the use of alternative modalities of monitoring isoimmunized pregnancies in patients with hyperbilirubinemia.

Cardiovascular effects of ritodrine tocolysis: a new noninvasive method to measure pulmonary capillary pressure during pregnancy.

The cardiovascular effects of ritodrine tocolytic therapy were assessed by noninvasive simultaneous recordings of indirect carotid pulse, electrocardiogram (ECG), phonocardiogram, and M-mode echocardiogram in 12 patients in preterm labor. The study was performed before and during infusion, and afterward when the patient was on oral drug therapy. Ritodrine therapy increased heart rate, left ventricular fractional shortening, pre-ejection period/left ventricular ejection time ratio, and cardiac index. A progressive rise in pulmonary capillary pressure was observed in all patients, exceeding 18 mmHg (the threshold for the development of pulmonary congestion) in six patients. Systolic arterial pressure, left ventricular end-diastolic dimension, and plasma protein oncotic pressure remained unchanged during therapy. Ritodrine therapy resulted in a significant drop in diastolic blood pressure and peripheral vascular resistance. This noninvasive means of measuring cardiovascular parameters, including pulmonary capillary pressure, may be useful in monitoring patients who develop significant cardiovascular side effects during tocolytic therapy.

Glycosylated hemoglobins in normal pregnancy and gestational diabetes mellitus.

Glycosylated hemoglobins (HbA1) were measured in 23 nonpregnant women, 53 normal pregnant women, and 22 Class A diabetics; the results were 6.1 +/- 0.7%, 5.8 +/- 1.0%, and 7.0 +/- 1.3% in the 3 groups, respectively. The decrease in normal pregnancy was insignificant, whereas the increase in HbA1 in Class A diabetics over the other 2 groups was statistically significant (P less than 0.05). HbA1 did not correlate with maternal age, gravidity, or gestational age at the time of sampling. There was no difference in HbA1 between whites and blacks [patients with sickle hemoglobin (HbS) were excluded] (P = 0.35), nor between primigravidas and multigravidas (P = 0.8). HbA1 levels did not correlate with the birth weight ratios in either normal pregnancies (r = 0.06, P = 0.7) or in Class A diabetics (r = -0.4, P = 0.09). This is probably due to the long interval between HbA1 determination and delivery (9.9 weeks).

Cryptococcal meningitis in pregnancy.

Cryptococcal meningitis was diagnosed in a pregnant woman at 21 weeks' gestation. The availability of fetal tissues, blood, and amniotic fluid in such a patient receiving therapy with amphotericin B plus flucytosine afforded the opportunity to study the effects of the disease and therapeutic agents on the developing fetus. The amphotericin B concentration in amniotic fluid was 0.25 micrograms/ml and that of flucytosine was 168 micrograms/ml. The concentrations in cord blood were 0.3 micrograms/ml and 64.7 micrograms/ml, respectively. No evidence was found of amphotericin B or flucytosine toxicity in fetal tissues, although exposure of the fetus to these compounds was of brief duration.

The human uterotubal junction: a scanning electron microscope study during different phases of the menstrual cycle.

Uterotubal junctions from surgically extirpated human uteri were examined. The specimens were obtained during different phases of the menstrual cycle. The interstitial portions of the tubes together with the cornual areas were dissected, excised, and their luminal surfaces exposed. The specimens were then processed for scanning electron microscopy. The surface epithelium of both the cornual endometrium and interstitial endosalpins. Ciliated cells were more numerous in the endosalpinx. Cyclic changes in ciliated cells were minimal, while cyclic secretory activity was demonstrated, especially in the endometrium. The transitional area between the endometrium and the endosalpinx was characterized by a marked increase in the number of ciliated cells, and a tendency of the secretory cells to assume a flattened, polygonal shape. These morphologic features suggest a possible role in the transport and/or maintenance of spermatozoa and/or ova.

PIP: Uterotubal junctions from hysterectomy specimens, obtained at different phases of the menstrual cycle, were examined by scanning electron microscopy. Ciliated and secretory cells, with common morphologic characteristics, were observed in the surface epithelium of both the cornual endometrium and interstitial endosalpinx, with ciliated cells being dominant in number in the endosalpinx. Changes in ciliated cells were minimal during the menstrual cycle, though secretory cell act ivity was apparent, particularly in the endometrium. A considerable inc rease in the number of ciliated cells was observed in the transitional area between the endosalpinx and the endometrium. There was also a tendency of the secretory cells to assume a flattened, polygonal shape in the same region. The observed changes are suggestive of a possible role of the uterotubal junction in the transport of maintenance of spermatozoa or ova.

Benign intracranial hypertension in pregnancy: current diagnostic and therapeutic approach.

Four cases of benign intracranial hypertension (BIH) in pregnancy are presented. Literature regarding this rare entity is reviewed. Various diagnostic and therapeutic approaches in the management of BIH are described, with special emphasis on the newer neurodiagnostic and neurosurgical approaches. Guidelines have been suggested in diagnosing and managing this syndrome in pregnancy.

Antenatal diagnosis of fetal intracranial anomalies.

Defects in the central nervous system (CNS) are the most devastating of the various fetal malformations that can be sonographically diagnosed. The sonographer often initiates a decision-making process that presents the patient with difficult options. An accurate and reliable sonographic diagnosis becomes an essential part of this evolving aspect of obstetric care. In this paper, some of the major defects of the CNS that have been diagnosed sonographically are presented with a brief outline of the pathologic features, diagnostic features, the prognosis, as well as management options. Most of these malformations are serious enough so that termination of pregnancy is usually offered if the diagnosis is made prior to the age of viability and, for some malformations (ie, hydranencephaly, alobar holoprosencephaly), even later. Intrauterine treatment, principally ventriculoamniotic shunting, remains an investigational procedure. A diagnosis of a serious or lethal malformation allows the obstetrician to choose not to perform a cesarean section because of fetal distress or dystocia due to macrocephaly in such "doomed" fetuses. On the other hand, cesarean section may be the preferred route of delivery for fetuses with other malformations (eg, meningomyelocele).

Realtime sonographic diagnosis of fetal dysplastic kidney.

A case of unilateral renal dysplasia was diagnosed in utero using realtime scanning. The diagnosis was confirmed neonatally and the affected kidney was surgically removed. Pathologic findings were consistent with the features of this malformation. The echographic characteristics of renal dysplasia and the differential diagnosis are described. The potential uses of ultrasonography in the diagnosis and follow-up of pregnancies associated with or at risk of renal malformations are discussed.

Effect of fetal sex and race on amniotic fluid lecithin concentration.

Amniotic fluid lecithin phosphorus concentration (AF-Lec) was measured in 209 healthy women at 31.7-42.7 weeks gestation. The patients were divided into four groups according to race and fetal sex. No differences in AF-Lec between black and white nor between male and female fetuses were found. The relationship of AF-Lec to gestational age and the incidence of "mature" AF-Lec was not different among the four groups. We conclude that there is no effect of fetal sex, race, or the interaction between them on fetal lung development as measured by AF-Lec.

Diabetes mellitus and pregnancy: management and results.

A protocol for the diagnosis and management of diabetes mellitus in pregnancy is outlined. It entails frequent prenatal visits, strict metabolic control, a program for antepartum fetal surveillance using estriols and contraction stress testing, liberal hospitalization, fetal lung maturity assessment, individualization of the time of induction of labor and careful intrapartum fetal monitoring. The results of such a protocol over a two-and-a-half-year period involving 84 gestational (GD) and 23 insulin-dependent (IDD) diabetic pregnant women is described. The incidence of preterm labor (less than 37 weeks) was 7.1% in GD and 39% in IDD. The cesarean section rate was 15.4% in GD and 56.5% in IDD. The incidence of macrosomia was 20% in GD and 13% in IDD. There was one antepartum stillbirth in GD due to a true knot of the cord, and there were no neonatal deaths in either group, for a perinatal mortality rate of less than 1%. Neonatal morbidity was also decreased. Respiratory distress syndrome occurred in only one neonate of an IDD. The success of such a protocol in decreasing perinatal morbidity and mortality justifies the effort and cost expended.

Diabetic halo. A reversible ultrasonic sign.

Two pregnant women with poorly controlled diabetes mellitus were noted to have "edematous" fetuses on ultrasonography. There was abdominal wall "edema" in one and scalp "edema" in both fetuses. In light of what is known about the fetal body composition in diabetic pregnancies, we propose that this sonographic appearance reflects increased fat deposition, rather than accumulation of edema fluid, in the fetal subcutaneous tissue; it has been called "diabetic halo." In a patient who had been treated for eight weeks but not in another, in whom treatment was only for 1.5 weeks, these sonographic features were reversed. This is probably in decreased fat deposition in the fetus. We suggest that this ultrasonographic sign be added to our means of diagnosing uncontrolled diabetic pregnancies and of monitoring the degree of control in diabetic pregnancies.

Pregnancy in a patient with type II polyendocrinopathy. A case report.

The rare association of Addison's disease and autoimmune hypothyroidism (Schmidt's syndrome) occurred during two pregnancies in the same woman. The association of Addison's disease and pregnancy is serious, and affected patients should be followed closely for electrolyte homeostasis.

Ultrasonographic prenatal diagnosis of hydranencephaly. A case report.

Hydranencephaly was diagnosed with a prenatal ultrasound examination, and the results were correlated with the autopsy findings.

Sickle-cell-induced hematuria in pregnancy. The current diagnostic and therapeutic approach.

Hematuria is a rather frequent complication in patients with sickling disorders. However, the occurrence, incidence and management of this complication during pregnancy have not been discussed in the medical literature. We treated three patients with sickle-cell-induced hematuria in pregnancy and developed an approach we find useful for such patients.