Transabdominal cervical cerclage in triplet pregnancies and risk of extreme prematurity and neonatal loss.

There are no reports indicating the effect of prophylactic transabdominal cerclage (TAC) on the prolongation of multifetal pregnancies. We report the use of TAC in triplets, which evolved over 20 years in one practice. A retrospective cohort study of triplet pregnancies was conducted. Obstetric and neonatal outcomes were compared among women who underwent a prophylactic TAC or transvaginal cerclage and no cerclage. Of the 141 women who delivered triplets, prophylactic TAC was associated with reduced incidence of extreme prematurity and improved incidence of neonatal/postnatal survival. With the exception of mode of conception, prepregnancy weight, and the use of home monitoring uterine activity monitor, procardia and terbutaline, no major differences were found in terms of patient characteristics and pregnancy and delivery management among the three groups. It was concluded that in triplet pregnancies, prophylactic placement of a TAC appears to lower the incidence of delivery before 28 weeks.

Peripartum cardiomyopathy presenting as lower extremity arterial thromboembolism. A case report.

BACKGROUND: Although venous thromboembolism has been associated with peripartum cardiomyopathy, there have been no prior reports of lower extremity arterial thromboembolism complicating cardiac failure. CASE: A 38-year-old woman, gradiva 5, para 5, presented on postpartum day 9 with left pedal parasthesia. Lower extremity angiography found acute thrombotic emboli in the left popliteal artery, right tibial artery and right peroneal artery. When respiratory decompensation ensued, a transthoracic echocardiogram revealed global hypokinesis and a left ventricular ejection fraction of 30%. The patient had an uneventful recovery after treatment with digoxin, furosemide and intravenous heparin. CONCLUSION: Lower extremity arterial thromboembolism may be the initial manifestation of peripartum cardiomyopathy.

Recurrent fetal cystic hygroma with normal chromosomes: case report and review of the literature.

Recurrence of fetal cystic hygroma in subsequent pregnancies is extremely rare. A review of the literature to date revealed only two other reports of recurrence with normal fetal karyotypes documented in at least two of the affected pregnancies. At 11 weeks' gestation, the fetus of a 19-year-old gravida 3 para 0 was discovered to have a large cystic hygroma. Subsequent evaluation during the second trimester revealed increasing size of the septated nuchal mass and ascites. A 46,XX fetal karyotype was noted in her two prior pregnancies, both of which had also been complicated by the development of cystic hygroma and nonimmune hydrops. Cystic hygroma, associated with a normal karyotype, can be inherited as an autosomal recessive trait.

Successful pregnancy outcome in a woman with a gain-of-function mutation of the calcium-sensing receptor. A case report.

BACKGROUND: Gain-of-function mutations of the calcium-sensing receptor gene have recently been identified as a cause of familial hypercalciuric hypocalcemia. There have been no earlier reported cases of pregnancy among patients with this disorder. CASE: A 26-year-old woman, gravida 1, para 0, was diagnosed at age 18 as being a heterozygous carrier of a mutation in the calcium-sensing receptor gene. Stable maternal hypocalcemia was achieved during pregnancy with high-dose calcium and 1,25-dihydroxyvitamin D3 therapy. Prenatal diagnosis was accomplished via amniocentesis at 16 weeks' gestation. The patient underwent cesarean delivery at 35 5/7 weeks' gestation after developing the HELLP syndrome. CONCLUSION: Patients with mutations of the calcium-sensing receptor may have a successful pregnancy outcome. This abnormality may be transmitted to the fetus via an autosomal dominant pattern.

Desmoid tumor of the larynx complicating pregnancy: a case report.

Desmoid tumors are locally invasive fibrous neoplasms that arise from musculoaponeurotic structures. We report the first case of a desmoid tumor of the larynx complicating pregnancy. At 21 weeks' gestation fiberoptic and indirect otolaryngologic examination of the patient's larynx revealed a submucosal tumor involving the left true vocal cord, ventricle of the larynx, and false vocal cord. Histopathologic examination revealed areas of extensive fibrosis intermixed with degenerated vocal cord skeletal muscle. Despite a subtotal excisional biopsy, growth of the desmoid tumor continued during pregnancy. Endoscopic evaluation 9 weeks post partum revealed complete regression of the tumor.

Enterovesical fistula complicating pregnancy. A case report.

BACKGROUND: Enterovesical fistula is a rare cause of recurrent urinary tract infections. This condition is unusual in young people as common etiologies include diverticular disease and cancer. When an enterovesical fistula occurs in women of childbearing age, Crohn's disease is a likely cause. To our knowledge, enterovesical fistula complicating pregnancy has not been reported before. CASE: A pregnant woman with recurrent urinary tract infections was evaluated. Cystoscopy was suggestive of an enterovesical fistula, which was confirmed by charcoaluria following oral charcoal administration. The prenatal course was complicated by two episodes of hemorrhagic cystitis despite antibiotic prophylaxis. The patient had an uncomplicated term spontaneous vaginal delivery. An upper gastrointestinal series performed postpartum was suggestive of Crohn's disease and confirmed an enterovesical fistula. Surgical repair was successfully performed three months following delivery, revealing Crohn's disease. CONCLUSION: Enterovesical fistula may be an unusual cause of recurrent urinary tract infections in pregnancy. In this case, enterovesical fistula was the presenting symptom of Crohn's disease.

Streptococcus viridans intra-amniotic infection associated with antecedent cunnilingus.

Introduction of bacteria into the amniotic cavity has been associated with oral sex through an ascending infectious route. Previous reports have implicated both Capnocytophaga and Fusobacterium nucleatum via this process. We report a case of Streptococcus viridans intra-amniotic infection occurring at 25 weeks' gestation. Patient questioning revealed a close temporal relationship between the onset of symptoms and previous episodes of cunnilingus. The diagnosis of subclinical bacterial colonization of the amniotic fluid should be considered in patients presenting with preterm labour and no apparent aetiology. A history of recent cunnilingus may be associated with the presence of Streptococcus viridans in the amniotic fluid.

Differential transmission of adenovirus in a twin pregnancy.

BACKGROUND: Intrauterine adenovirus infection has been associated with nonimmune hydrops. We describe a twin pregnancy in which adenovirus was demonstrated by polymerase chain reaction in the amniotic fluid of one twin afflicted by hydrops. Adenovirus was absent in the amniotic fluid of the other twin. CASE: A 25-year-old, gravida 3, para 1, with twin gestation at 20 weeks' gestation was noted on ultrasound anomaly screen to have hydrops associated with twin B. Polymerase chain reaction analysis of amniotic fluid revealed adenovirus in twin B with none noted in twin A. At 26 weeks' gestation both infants died. CONCLUSION: This case demonstrates differential transmission of adenovirus in a twin pregnancy. One twin developed hydrops fetalis possibly secondary to adenovirus infection.

Adjunctive color Doppler ultrasonography in second-trimester transabdominal amnioinfusion.

Transabdominal amnioinfusion improves the diagnostic accuracy of ultrasonography in pregnancies complicated by second-trimester oligohydramnios. Needle localization may be difficult because of patient obesity or the absence of an acoustic window. The two cases presented demonstrate that color Doppler imaging facilitates amnioinfusion by visualizing the injection jet of free-flowing infusate, confirming intraamniotic needle placement.

Pregnancy complicated by multiple endocrine neoplasia type IIA (Sipple's syndrome).

A patient with preexisting multiple endocrine neoplasia type IIA had normal 24-hour urinary metanephrine and vanillylmandelic acid excretions before and during pregnancy. After a benign prenatal course, the patient had a term spontaneous vaginal delivery. Multiple endocrine neoplasia type IIA antedating pregnancy may be associated with a normal obstetric outcome in the absence of a phenochromocytoma.

Use of surgical pass trays to reduce intraoperative glove perforations.

This randomized prospective study evaluated the surgical pass tray to reduce intraoperative glove perforation during cesarean delivery. Surgical team members were assigned to employ normal instrument pass techniques or surgical pass tray during all cesarean deliveries. Surgical team members were asked to record their surgical role and level of training. Gloves were collected and tested using standard hydrosufflation techniques. Additional variables studied were patient weight, surgical indication, estimated blood loss, and length of surgery. A total of 192 cesarean sections were performed during the study period, for which 165 were studied. Data collection was considered adequate in 156 cases. Four hundred forty-four pairs of gloves were collected and tested, including 38 double glove sets. Seventy-eight perforations were noted in 444 pairs of gloves, including 11 in the double glove sets. Among surgeries assigned to use pass trays, 221 pairs of gloves were obtained with 42 (19.0%) perforations noted. Surgeries assigned to the control group contributed 223 glove sets of which 36 (16.1%) perforations were noted (P = .5). There were no complete perforations noted in the total of double glove sets. The frequency of glove perforations is not reduced by using surgical pass trays. While there is no demonstrated benefit in using pass trays there appears to be little adverse impact.

Single dose cefazolin prophylaxis for postcesarean infections: before vs. after cord clamping.

The objective of this study was to test the hypothesis that 1 g of cefazolin administered preoperatively is no more effective than the same dose administered after cord clamping in preventing postcesarean infectious morbidity. Ninety consecutive laboring subjects undergoing cesarean delivery at > or = 37 weeks gestation were randomized by computer to receive 1 g of cefazolin intravenously preoperatively or after cord clamping in a double-blinded, placebo-controlled study. The 2 groups were compared for differences in maternal and neonatal demographics, and intrapartum and operative characteristics associated with postcesarean infection. Primary maternal outcome variables were endometritis or wound infection. Secondary outcomes included intra-abdominal abscess formation, septic pelvic thrombophlebitis, pneumonia, or urinary tract infection. Neonatal outcomes included sepsis screens, sepsis, pneumonia, and meningitis. Subjects were followed 6 weeks postoperatively for late complications. Subjects receiving cefazolin preoperatively or after cord clamping had similar maternal and neonatal demographics, and intrapartum and operative characteristics. One patient in the former group experienced both endometritis and wound infection. In the latter group, 2 wound infections and 1 case of endometritis occurred (P = 0.35). There were no secondary maternal infections. Two infants treated for pneumonia and 2 other infants readmitted with febrile illnesses were born to mothers receiving cefazolin preoperatively. Overall, 8 neonates were evaluated for suspected sepsis and all had negative studies. Six of these infants' mothers received cefazolin preoperatively (P = 0.28). In conclusion, 1 gram of cefazolin preoperatively is no more effective than the same dose administered after cord clamping in preventing postcesarean infectious morbidity, but is associated with a trend toward increased suspected sepsis in the newborn. However, this trend may be related to differences between the study groups' risk factors for infection.

Intrapartum fetal atrial bigeminy--diagnostic and therapeutic role of the fetal scalp stimulation test.

Concern for fetal hypoxia often leads to cesarean delivery when persistent fetal bradycardia is identified. A fetus with premature atrial contractions had a prolonged second-stage heart rate of 80 beats/min. Intrapartum echocardiography and electronic fetal heart rate monitoring distinguished bradycardia caused by blocked atrial bigeminy from hypoxic bradycardia. The fetal scalp stimulation test documented normal acid-base balance and normalized the ventricular rate, avoiding cesarean delivery.

The role of cyanide in the removal of type 2 copper from laccase.

We have improved a method for the removal of the type 2 copper from tree laccase under anaerobic reducing conditions and developed a mechanistic model. We identify two key steps in the reaction: (i) dissociation of copper(I) catalyzed by trace levels of cyanide in a weakly acidic medium and (ii) sequestration of the released metal by an appropriate chelator such as 2,9-dimethyl-1,10-phenanthroline. We maintain a steady-state concentration of cyanide in a pH 5.5 acetate buffer under a constantly exchanging nitrogen atmosphere by introducing a cyanometalate ion as a cofactor or by continuously injecting the ion into the protein solution. The type 2-depleted product is identical to previous preparations as regards its spectral properties, activity level and ability to recombine with copper(I). The mechanistic insights appear to be quite general and should form the basis for the development of methods for removing the type 2 copper from other related systems.

Active expectant management in very early gestations complicated by premature rupture of the fetal membranes.

Premature rupture of the membranes (PROM) in the previable gestation is frequently associated with fetal or neonatal death. Passive expectant management is successful in only a small minority of cases. Women presenting with PROM at < or = 27 weeks' gestation were treated with tocolysis and prophylactic antibiotics and delivered electively for lung maturity. The corrected perinatal survival was > 92%. The mean latency phase was 21.6 days (+/- 18.12 SD). Twenty-one percent of patients presented in labor; the mean latency phase for this subgroup was 14.4 (+/- 8.54) days. Nineteen patients (79%) had a latency phase > 7 days, and 14 (58%) had a latency phase > 14 days. Thirty-nine percent of infants required < 48 hours of mechanical ventilation. Six infants were delivered with intraventricular hemorrhage; in all cases it was grade 1 or 2. There were three (12.5%) postpartum infections and three septic neonates. Active expectant management using tocolysis and prophylactic antibiotics was associated with a prolonged latency phase, low infectious morbidity and good neonatal outcome.

Thromboxane synthetase inhibition produces maternal and fetal vasodilation during ovine pregnancy-induced hypertension: a Doppler flow velocimetric study.

Changes in maternal and fetal umbilical arterial vasoreactivity during ovine pregnancy-induced hypertension and following intravenous administration of CGS 12970 [3-methyl-2-(3-pyridyl)-1-indoleoctanoic acid] were assessed. Continuous wave Doppler flow velocimetry was used to assess vascular reactivity during normotensive baseline, during ovine pregnancy-induced hypertension triggered by a 72-hour fast, and following thromboxane synthetase inhibition with CGS 12970. Uterine and umbilical arterial systolic/diastolic flow ratios increased significantly with the onset of sustained hypertension. After thromboxane synthetase inhibition, uterine and umbilical artery systolic/diastolic flow ratios were not different from baseline, and maternal blood pressure had returned to baseline values. These data indicate that thromboxane produces maternal and fetal vasoconstriction during ovine pregnancy-induced hypertension. Furthermore, these data provide strong evidence that thromboxane synthetase inhibition allows vasodilation, resulting in improved maternal and fetal condition.

Effects of thromboxane synthetase inhibition on maternal-fetal homeostasis in gravid ewes with ovine pregnancy-induced hypertension.

Simultaneous maternal indirect blood pressure measurements, electronic fetal heart rate monitoring, and ultrasonographic biophysical profile testing were used to assess maternal-fetal homeostasis in gravid ewes during gestational days 127 to 134 (term 146), during a 72-hour fast, and during treatment with thromboxane synthetase inhibitors CGS13080 and CGS12970. Seventy-five percent of the ewes (12 of 16) developed clinical signs of ovine pregnancy-induced hypertension, including maternal hypertension and fetal depression. In three untreated hypertensive ewes, pregnancy was terminated by spontaneous premature delivery, and one maternal death occurred after an eclamptic seizure. All nine ewes treated with one of the two thromboxane synthetase inhibitors responded to therapy with decreases in blood pressure and resolution of fetal depression. These nine ewes completed gestation, and were delivered at term. These data indicate that therapy with thromboxane synthetase inhibitors in this animal model of preeclampsia results in profoundly beneficial effects and suggest that further studies of thromboxane synthetase inhibitors are warranted in preeclampsia.