Pregnancy and active Huntington disease: a rare combination.

We describe the complicated course of a rare pregnant woman with symptomatic Huntington disease (HD) and discuss multidisciplinary care issues that may be encountered. A 31-year-old gravida 2, para 1 with advanced HD was admitted at 30 weeks gestation for preterm labor. Her course was complicated by progressive cognitive and physical impairment, dysphagia, malnutrition, diabetes insipidus, aspiration pneumonia, chorioamnionitis, preterm delivery and pyelonephritis. Pregnant women with symptomatic HD may present multiple challenges requiring extensive multidisciplinary input.

Effect of vaginal pH on efficacy of the controlled-release dinoprostone vaginal insert for cervical ripening/labor induction.

OBJECTIVE: To evaluate whether vaginal pH alters the efficacy of the controlled-release dinoprostone vaginal insert (Cervidil) for cervical ripening/labor induction. METHODS: Thirty-four women with an unfavorable cervix undergoing labor induction were enrolled in this prospective, double-blind investigation. Vaginal pH and Bishop score assessments were made by an independent examiner. All women received preinduction with the dinoprostone vaginal insert 10 mg intravaginally for 12 h. Twelve hours later, oxytocin induction initiated according to the standardized protocol and outcome data were collected. RESULTS: Mean (+/- SD) initial vaginal pH was 4.9 +/- 0.5 for the study cohort. No significant differences were noted between women with a high vaginal pH (> 4.5, n = 18) and those with a low vaginal pH (< or = 4.5, n = 16) with respect to maternal age, parity, gestational age, or initial Bishop score. Similarly, Bishop score change over the preinduction interval (3.2 vs. 3.3), time to active labor (28.6 vs. 24.6 h) and time to delivery (33.7 vs. 31.4 h) were not significantly different between the low and the high pH groups, respectively. Linear regression analysis revealed no significant association between vaginal pH and Bishop score change during the preinduction interval, time to active labor, time to complete dilatation, or time to delivery. CONCLUSION: Vaginal pH does not appear to influence the efficacy of the controlled-released dinoprostone vaginal insert for cervical ripening/labor induction.

Chronology of neurological manifestations of prenatally diagnosed open neural tube defects.

OBJECTIVE: To evaluate the incidence and chronology of sonographic markers of neurological compromise in prenatally diagnosed neural tube defects. METHODS: We reviewed our ultrasound database from 1988 to 1999 to identify all cases of prenatally diagnosed neural tube defects. All patients received an initial detailed targeted ultrasound evaluation with subsequent evaluations every 4-6 weeks. Cases involving multiple congenital anomalies, aneuploidy, or inadequate follow-up were excluded. Specific ultrasound markers assessed included the presence of ventriculomegaly (> 10 mm) and clubfoot. RESULTS: Forty-seven cases of neural tube defects were identified over the study interval. After exclusions, 42 cases were available for evaluation. The overall incidence of ventriculomegaly and clubfoot in the study cohort was 86% and 38%, respectively. In the 33 patients with initial ultrasound examination performed at < 24 weeks' gestation, 76% (25/33) had evidence of ventriculomegaly and 30% (10/33) and clubfoot. Only 9% (1/11) of the patients managed expectantly developed evidence of ventriculomegaly and 3/11 (27%) developed clubfoot from the time of the initial ultrasound examination to delivery. CONCLUSIONS: Ultrasound markers of neurological compromise are early and frequent findings associated with fetal neural tube defects. Development of ventriculomegaly is an uncommon occurrence later in gestation, while the risk for developing clubfoot appears to increase as gestation progresses.

Elevated amniotic fluid ferritin levels are associated with inflammation-related pregnancy loss following mid-trimester amniocentesis.

OBJECTIVE: Occult infection accounts for up to 12% of pregnancy losses following genetic amniocentesis. Elevated serum and cervical fluid levels of ferritin, an acute-phase reactant, have been associated with spontaneous preterm delivery. We determined the association between amniotic fluid (AF) ferritin levels and post-amniocentesis pregnancy loss. METHODS: We performed a case-control study involving 66 women with a non-anomalous fetus who had a spontaneous pregnancy loss within 30 days following genetic amniocentesis and 66 term controls matched for maternal age, gestational age, time of test and indication for amniocentesis. Amniotic fluid ferritin and interleukin-6 (IL-6) levels were measured using commercially available kits. RESULTS: Mean (+/- SD) AF ferritin levels were similar between the cases (19.3 +/- 21.4 ng/ml) and the controls (19.8 +/- 22.7ng/ml) (p = 0.9). Mean (+/- SD) AF IL-6 levels were significantly higher in the women with post-amniocentesis pregnancy loss (4.0 +/- 13.1 ng/ml) than in controls (0.5 +/- 0.7 ng/ml) (p = 0.04). A significant proportion (12.1%, 8/66) of the women with post-amniocentesis pregnancy loss had elevated amniotic fluid IL-6 levels (> 3 SD, 2.5 ng/ml) indicating inflammation, as compared to none in the control group (p = 0.01). In this subgroup of women with pregnancy loss and elevated IL-6 levels, AF ferritin levels were significantly elevated (52.0 +/- 45.5 ng/ml) compared to the level in women who had a term delivery (19.8 +/- 22.7 ng/ml) (p = 0.002), and were strongly correlated with IL-6 levels among the cases (r = 0.67, p < 0.001). CONCLUSION: The strong correlation of AF ferritin with IL-6 levels, along with the high ferritin values in cases with high AF IL-6, indicates that ferritin is a marker of inflammation in asymptomatic women destined to have an early pregnancy loss.

The association of isolated mild fetal hydronephrosis with postnatal vesicoureteral reflux.

OBJECTIVE: We evaluated the incidence of vesicoureteral reflux in fetuses with prenatally detected isolated mild fetal hydronephrosis. METHODS: Fetuses with isolated mild fetal hydronephrosis (defined as a fetal renal pelvis anteroposterior diameter of > or = 4 and < 10 mm before 24 weeks' gestational age) were prospectively evaluated with postnatal renal ultrasound and voiding cystourethrography within the first few weeks after delivery. Infants were evaluated regardless of whether or not renal pelvic dilatation was seen on postnatal ultrasound examination. RESULTS: Forty cases of mild fetal hydronephrosis were identified from the 5,432 patients cared for at our institution from February 1996 to December 1998 (overall incidence: 1/136). Cases involving aneuploidy (n = 1) and inadequate follow-up (n = 5) were excluded from the investigation. One fetus with documented mild hydronephrosis early in gestation had spontaneous resolution and did not undergo postnatal evaluation. Of the remaining 33 infants, 32 underwent postnatal renal ultrasound examination and all had voiding cystourethrography. Vesicoureteral reflux was identified in five (15%) of the neonates. Eighty per cent (four out of five) of these infants were male. Resolution of vesicoureteral reflux occurred in 75% (three out of four) of the infants available for follow-up within 2 years of birth. CONCLUSIONS: Isolated mild fetal hydronephrosis is associated with vesicoureteral reflux on postnatal voiding cystourethrography.

Lethal pulmonary hypoplasia after in-utero myelomeningocele repair.

BACKGROUND: In-utero surgical repair of fetal myelomeningocele has been performed as a means to improve the postnatal condition of affected infants. CASE: A nulliparous woman underwent in-utero surgical repair of a fetal lumbosacral myelomeningocele at 24 weeks' gestation. Her postoperative convalescence was complicated by pulmonary edema, abdominal pain, chronic oligohydramnios, and preterm labor. The infant was delivered by cesarean at 33 weeks' gestation, but expired from respiratory distress caused by pulmonary hypoplasia at 9 hours of age. CONCLUSION: Until the benefits of in-utero repair of fetal myelomeningoceles are determined by well-controlled clinical trials, this technique remains investigational. Physicians and their patients who are considering this procedure must be fully aware of the potential risks that can occur.

Magnesium sulfate as a tocolytic agent.

Although magnesium sulfate is widely used as a tocolytic agent in the hope of preventing spontaneous preterm birth, there is a paucity of data from large well-designed randomized clinical studies demonstrating the efficacy of magnesium sulfate therapy. Given the potential for untoward side effects and the inherent risks of magnesium sulfate therapy, a thorough understanding of the potential risks and benefits of this agent is needed. To accomplish this understanding we have provided a detailed review the history, pharmacology, physiology, maternal/fetal side effects, and tocolytic efficacy of magnesium sulfate.

Cardiac disease in pregnancy.

Cardiovascular adaptations of pregnancy are generally well tolerated in the healthy gravida; however, these changes can place undue stress on women with underlying cardiovascular disease and can result in increased risk for morbidity and mortality. In this article, we will review issues related to preconceptional counseling, cardiovascular adaptations of pregnancy, and the prognosis and management of the gravida with cardiac disease in pregnancy.

In utero erythrocyte transfusion for fetal xerocytosis associated with severe anemia and non-immune hydrops fetalis.

Hereditary xerocytosis is a rare hemolytic anemia occurring secondary to a defect in cell membrane potassium flux. We report a case of severe fetal anemia and non-immune hydrops secondary to hereditary xerocytosis that was managed successfully with in utero erythrocyte and albumin transfusion.

Pneumonia in pregnancy.

Although the advent of broad-spectrum antibiotics has markedly improved the maternal outcomes of pneumonia complicating pregnancy, pneumonia remains a significant condition that may complicate pregnancy. This article has reviewed the inherent physiologic respiratory changes that accompany pregnancy and the common causes of pneumonia in the pregnant woman. The clinical course of bacterial pneumonia seems to be minimally altered by pregnancy, whereas viral pneumonia carries a significantly worse prognosis when encountered during gestation. Prompt diagnosis, the initiation of respiratory support, and appropriate antimicrobial/antiviral therapy are key components of therapy for women in whom pregnancy is complicated by pneumonia. Because preterm labor frequently accompanies pneumonia, women should be monitored closely for the occult onset of preterm labor and appropriate interventions initiated if indicated. Perhaps even more important than interventions to treat acute pneumonia are efforts directed at active immunization or prophylactic therapy to prevent the development of pneumonia in select patient populations. The combination of these efforts is essential to optimize medical care for pregnant women.

Disease of the gallbladder and pancreas in pregnancy.

Although maternal mortality and morbidity are substantially lower today than decades ago, perinatal mortality and morbidity secondary to gallbladder and pancreatic disease remain excessive. Improvements in perinatal mortality reflect improvements in neonatal intensive care because most of the morbidity stems from prematurity. Prompt recognition of cholelithiasis and pancreatitis and liberal hospitalization have been associated with a decline in poor outcomes. The decision to switch from medical to surgical management must be made individually, taking into account past history, gestational age, and the response of current disease to conservative therapy.

Delayed postpartum hemorrhage: a rare presentation of carbon monoxide poisoning.

A 41-year-old woman presented with postpartum hemorrhage and altered mentation. A markedly elevated serum carboxyhemoglobin level was noted. Oxygen therapy was initiated with resolution of the patient's bleeding and improved mental status. Carbon monoxide poisoning is a rare and previously unreported cause of postpartum hemorrhage resulting from a unique pathophysiologic mechanism.

Labor induction.

Labor induction has become commonplace in modern obstetrics. The increasing rate of labor induction has probably played a role in the increased rate of cesarean delivery observed in the United States during the past few decades. Clearly, the favorability of the cervix has a substantial impact on the potential success of any labor induction. Induction in the setting of an unfavorable cervix can result in prolonged induction, prolonged hospitalization, failed induction, and an increased cesarean delivery rate. In this modern era of healthcare reform and cost containment, the identification of therapeutic strategies to enhance the success and cost-effectiveness of labor induction are of great interest. Ongoing research is needed to advance our knowledge of the mechanisms of parturition and cervical ripening in order to direct interventions for labor induction more effectively.

Cardiovascular effects of intravaginal misoprostol in the mid trimester of pregnancy.

OBJECTIVE: Our aim was to evaluate the cardiovascular effects of high-dose intravaginal misoprostol administration by means of transthoracic electrical bioimpedance monitoring. STUDY DESIGN: Healthy women undergoing mid trimester pregnancy interruption with intravaginal misoprostol were eligible for this prospective observational study. Baseline blood pressure was obtained for 1 hour and transthoracic electrical bioimpedance monitoring was performed before misoprostol administration, 600 microg vaginally. Posttreatment assessments were made every 15 minutes for a total of 4 hours, with patients in a left lateral recumbent position. Heart rate, mean arterial pressure, cardiac index, stroke index, systemic vascular resistance index, and end-diastolic volume index were determined. Measurements were averaged for 30-minute intervals and reported as mean +/- SD. Statistical analyses included the paired t test and repeated-measures analysis of variance. RESULTS: Nine women consented to have transthoracic electrical bioimpedance monitoring, and no statistically significant changes in any of the measured cardiac parameters for the 4-hour monitoring interval were noted. Direct comparisons between the pretreatment and 2-hour posttreatment intervals (reported time peak of blood misoprostol levels) also revealed no significant differences in the cardiovascular index values. CONCLUSION: High-dose intravaginal misoprostol in the mid trimester does not alter maternal cardiac function as measured by transthoracic electrical bioimpedance.

Effect of vaginal pH on efficacy of misoprostol for cervical ripening and labor induction.

OBJECTIVE: We sought to evaluate whether vaginal pH has an effect on the relative efficacy of misoprostol for cervical ripening and labor induction. STUDY DESIGN: Thirty-seven gravid women with an unfavorable cervix and indication for labor induction were enrolled in this prospective, double-blind, observational study. Baseline assessments of cervicovaginal pH and Bishop score were made at the time of enrollment by an independent examiner. All patients received 50 microg misoprostol intravaginally every 6 hours for 12 hours. After the initial 12 hours of preinduction, a repeat Bishop score assessment was made by the same initial examiner. Patients not in active labor at 12 hours were placed on a standardized oxytocin induction regimen. Labor was managed by the on-call obstetric team, who remained blinded to pH assessment. Clinical outcomes were evaluated. Statistical analyses were made by the Student t test, the Fisher exact test, and linear regression analysis. RESULTS: Average initial vaginal pH was 4.8 +/- 0.5 (range, 3.5-7.0) for the study cohort. No significant differences were noted between those patients with low vaginal pH (< or =4.5) compared with those with high pH vaginal (>4.5) with respect to maternal age, parity, gestational age, or initial Bishop score. Similarly, Bishop score change over preinduction interval (5.6 vs 4.9), time to active labor (16.3 vs 17. 1 hours), time to complete dilatation (20.0 vs 19.9 hours), and time to delivery (21.0 vs 21.6 hours) were not significantly different between the low and high pH groups, respectively. Linear regression analysis revealed no significant association between vaginal pH and Bishop score change during preinduction interval, time to active labor, time to complete dilatation, or time to delivery. CONCLUSION: Vaginal pH does not appear to influence the efficacy of intravaginally administered misoprostol for cervical ripening and labor induction.

Shoulder dystocia. Rotational maneuvers revisited.

Shoulder dystocia is an acute obstetric emergency that necessitates prompt, skillful intervention in order to prevent serious fetal trauma or death. Of the maneuvers described to deal with this difficult problem, rotational maneuvers are among the most ingenious. In spite of the effectiveness of these techniques, various technical deviations have led to the incorrect description and implementation of these maneuvers. This review of the rotational maneuvers used to counter shoulder dystocia gives particular attention to the techniques described originally.