Osteomyelitis pubis occurring after spontaneous vaginal delivery: a case presentation.

BACKGROUND: Osteomyelitis pubis is an uncommon disorder. The clinical presentation is similar to that of osteitis pubis, which is a self-limiting condition. However, osteomyelitis pubis necessitates intensive intravenous antibiotic therapy and, frequently, surgery to effect a cure. CASE: A 33-year-old gravida II para 1001, Filipina vaginally delivered a 3802 gm baby on April 5, 1994. The delivery was complicated by shoulder dystocia. Her postpartum course was complicated by an abscessed tooth and pubic pain that was exacerbated by ambulation. On the twentieth postpartum day, she came to the emergency department with massive cellulitis of the mons veneris and labia majora. The results of an x-ray examination and bone scan were consistent with osteomyelitis of the pubis. The patient did not respond to multiple intravenous antibiotics, and surgical debridement was required. CONCLUSIONS: A diagnosis of osteomyelitis pubis should be considered for any patient who experiences pubic pain that is exacerbated by walking. Proper therapy consists of intravenous antibiotics and surgical debridement, as necessary, in patients who do not respond to antibiotics.

Early prenatal diagnosis: the first 100 cases of chorionic villus sampling at Ochsner Foundation Hospital.

Chorionic villus sampling is an exciting addition to prenatal diagnosis. With this procedure, accomplished quickly and with minimal discomfort at 9 to 11 weeks of pregnancy, information can be obtained about the fetal chromosomal complement. In addition, the fetus can be tested for a variety of disorders, such as sickle-cell disease, Tay-Sachs, and cystic fibrosis. The majority of fetal studies are normal, and such early prenatal testing provides relief of anxiety and opportunity for early maternal-fetal bonding.

Fertility following excision of a symptomatic craniopharyngioma during pregnancy: case report.

A 27-year-old woman in the second trimester of pregnancy presented with bitemporal hemianopsia. Total resection of a craniopharyngioma restored normal vision, and she delivered a normal infant at term. Permanent hormonal replacement therapy was not needed. Subsequent spontaneous pregnancy and delivery indicate that fertility was preserved. Literature review shows this case to be unique. Even with new developments in stereotactic radiotherapy, total excision remains a potentially achievable surgical goal.

Viable pregnancies after diagnosis of trisomy 16 by CVS: lethal aneuploidy compartmentalized to the trophoblast.

Increasing utilization of chorionic villus sampling (CVS) has lead to the discovery that the placenta can karyotypically be a very heterogeneous organ, and chromosomal mosaicism within the placental can confuse cytogenetic interpretation. Recently, confined placental mosaicism (confined regions of aneuploidy in the otherwise normal diploid placental and fetus) has been described involving a number of chromosomal abnormalities. Fetal trisomy 16 is considered uniformly lethal early in gestation. However, we present 3 cases of nonmosaic trisomy 16 confined regionally to the placenta. We discuss the possible etiology, impact on the developing fetus, and suggest an approach to the workup and evaluation of cases where the karyotype obtained on CVS is not compatible with the findings on ultrasound.

Successful pregnancy outcome in a patient with congenital biliary atresia.

Congenital biliary atresia is one of the most common congenital anomalies of the biliary tree. Without surgical correction, two-thirds of all cases of extrahepatic biliary atresia are fatal within 18 months. Historically, the preferred surgical procedure to correct this anomaly has been the Kasai procedure. Surgical treatment of congenital biliary atresia is associated with substantial perioperative morbidity and mortality, as well as long-term sequelae. Portal hypertension and hypersplenism can complicate the course of up to 50% of patients who survive for more than 2 years. Not surprisingly, few of these patients reach adulthood. We report the case of a woman with congenital biliary atresia surgically corrected with the Kasai operation who subsequently reached adulthood and became pregnant. Despite a prenatal course complicated by portal hypertension, bleeding esophageal varices, and hypersplenism, the woman delivered a healthy infant at 36.5 weeks' gestation.

Cord blood gas patterns identifying newborns at increased risk of group B streptococcal sepsis.

The effect of group B streptococcal sepsis acquired in utero on umbilical cord gas values is not known. Hypothesizing that fetal acid-base balance may be affected, we sought to identify a pattern of cord gas values that might detect newborns at increased risk of group B streptococcal sepsis. This review encompassed all newborns from January 1, 1986 to March 31, 1990 who manifested group B streptococcal sepsis as confirmed by a positive blood culture. An increased-risk cord gas profile was identified as an arterial pH less than 7.18 with either an arterial carbon dioxide pressure less than 59 mmHg or bicarbonate level less than 19 mEq/L. This pattern was found in four of 11 newborns with group B streptococcal disease but in only 43 of 4290 controls, yielding a relative risk of 51.7 (95% confidence interval 13.1-224.9). Our results suggest that a mild metabolic acidosis characterized by these indices may serve as an indicator of increased risk of early-onset group B streptococcal disease.

Vaginal birth after cesarean section: the impact of patient resistance to a trial of labor.

In spite of the relative safety and medical advantages of vaginal birth after cesarean section, the procedure continues to be underutilized in the private practice setting. To evaluate the hypothesis that resistance by the patient often precludes a trial of labor, an observational study was conducted of all women with a history of one prior cesarean section who were delivered in 1989 at Ochsner Foundation Hospital. The choices of 167 women and the judgments of their obstetricians were longitudinally recorded during the antepartum and intrapartum course. Patients routinely received the patient guide of the American College of Obstetricians and Gynecologists for vaginal birth after cesarean section. Ultimately, 50% of patients who were encouraged by their obstetrician toward vaginal birth after cesarean section opted for an elective repeat cesarean section without a trial of labor. Reasons for patient resistance are enumerated and potential future remedial proposals are discussed.

Sequential invasive assessment of fetal renal function and the intrauterine treatment of fetal obstructive uropathies.

Persistent fetal lower urinary tract obstruction carries a very poor prognosis secondary to damaged renal capacity and oligohydramnios, with its related pulmonary hypoplasia. Several attempts in the past several years to divert urinary flow via an intrauterine shunt have generally been disappointing, primarily because of poor patient selection. In this study we report our experiences with aggressive decompression of megacystis in 11 patients, the value in selected cases of sequential evaluations of fetal urine biochemistry, and the success of intrauterine bladder shunting procedures in appropriately chosen patients. Our data suggest that a single fetal urine determination may be insufficient to declare irreversible damage. Following decompression, improvement in urine biochemistry or its lack may be more likely representative of ultimate outcome. Decompression by either needle aspiration or intrauterine shunting is warranted in carefully selected cases and can save fetuses that are otherwise very likely doomed.

Fetal abdominal wall defect: a new complication of vesicoamniotic shunting.

Vesicoamniotic shunting for fetal obstructive uropathy is beneficial in selected cases. We report a new complication, fetal abdominal wall defect secondary to vesicoamniotic shunting. Placement of the shunt should be as low and as close to the fetal midline as possible in order to reduce the risk of this complication.

Uterine activity in patients with cervical cerclage.

Cervical cerclage is the traditional management of cervical incompetence. Uterine activity among these patients has never been studied. This retrospective report details the contraction frequency in 96 patients with cerclage who underwent daily home uterine activity monitoring. Twenty-three percent (22) developed preterm labor and 12% (11) had preterm delivery related to failed tocolysis or rupture of the membranes. Uterine activity in the group who developed preterm labor was significantly greater than in those who labored at term. The objective contraction frequency data obtained by uterine activity monitoring are of clinical significance to physicians managing such patients.