Preterm labor, placental abruption, and premature rupture of membranes in relation to maternal violence or verbal abuse.

OBJECTIVE: The prevalence of preterm labor (PTL) in prenatal populations has been estimated to be from 6.9 to 10.0%. It has been suggested that violence during pregnancy may be associated with an increase in antenatal complications. The hypothesis is that physical violence and verbal abuse in pregnancy lead to increased risk of PTL. METHODS: A cohort of 636 women attending the Adult Obstetrical Clinic for their first prenatal visit, between December 1989 and September 1990, were approached; 567 women enlisted as study participants. Study participants were interviewed 3 times during the course of their prenatal care, and 401 participants successfully completed their third prenatal interviews. Violence data were obtained during the third interview. Obstetrical and neonatal outcome data were obtained by abstracting the maternal and neonatal medical records. RESULTS: When stratified by levels of violence, women who experienced moderate or severe violence had incidences of PTL of 15.4 and 17.2%, respectively. Chi-square test for homogeneity revealed a significant difference among these groups. CONCLUSIONS: In our cohort of women, serious acts of verbal abuse and physical violence occurred with significant frequency. PTL was strongly correlated with increasing acts of violence with 4.1 times greater risk of PTL in women who experienced severe violence as compared to those who experienced no maternal abuse.

Complete hydatidiform mole and surviving coexistent twin.

Twin gestations consisting of a complete hydatidiform mole and coexisting fetus are rare and associated with an increased risk of persistent gestational trophoblastic tumor. Data were abstracted from 25 well-documented cases from the literature to which we added an additional case. Cases were then separated according to whether the pregnancy was evacuated before fetal viability (19 cases) or resulted in a surviving infant (7 cases). The previable and viable groups did not differ with respect to mean age, gravidity, parity, presenting symptoms, accuracy of sonographic diagnosis in identifying the molar component, uterine size at evacuation, or the presence of preeclampsia and theca lutein cysts. Statistically significant differences (P < .05) were detected between the previable and viable groups in estimated gestational age at evacuation (18.6 weeks vs. 33.0 weeks), the discrepancy between uterine size and estimated gestational age at evacuation (8.1 weeks vs. 1.0 weeks), and preevacuation serum hCG level (1,078,416 vs. 167,883 mIU/liter). Persistent GTT developed in 68.4 percent of the previable group patients and 28.6 percent of those in the viable group (P = .09). In patients with complete hydatidiform mole and coexistent fetus, fetal survival is associated with clinical characteristics suggestive of less exuberant molar growth. The advanced gestational age required to produce a viable, surviving fetus is not an independent risk factor for the development of persistent GTT.

Amniotic fluid alpha fetoprotein (AFAFP) and maternal serum alpha fetoprotein (MSAFP) in abdominal pregnancies: correlation with extent and site of placental implantation and clinical implications.

The hypotheses are evaluated that in abdominal pregnancies 1) elevated MSAFP is due to an altered maternal-placental interface, and 2) differences in MSAFP levels may reflect placental location within the peritoneal cavity. A review of 1,193 ectopic pregnancies from 1983-1993 identified three cases of advanced abdominal pregnancy. All three had undergone second trimester genetic amniocentesis for amniotic fluid alpha fetoprotein (AFAFP) and karyotype. The clinical course was reviewed (including presentation and surgical findings). MSAFP was elevated in two of the three cases (3.63 and 4.88 MoM). AFAFP and fetal karyotype were normal in all three cases. Elevated MSAFP values were associated with more extensive visceral implantation, longer surgical operative time, greater blood loss and transfusion requirements. Abdominal pregnancies with elevated MSAFP appear to have more extensive placental involvement of the abdominal viscera; this would, in fact, account for the elevated MSAFP values given the normal AFAFP.

Devastating sequelae of alloimmune thrombocytopenia: an entity that deserves more attention.

UNLABELLED: In alloimmune thrombocytopenia, maternal sensitization to a fetal platelet alloantigen results in fetal thrombocytopenia. Even in primipara, 20% of offspring can suffer intracranial hemorrhage, half of which occur in utero. Ninety percent of subsequent pregnancies will be equally or more severely affected. We describe two patients whose previous pregnancies were complicated by neonatal alloimmune thrombocytopenia (NAIT). As expected, NAIT recurred, with devastating sequelae in both cases. One case presented with hydrops fetalis, a previously unreported association; the other fetus developed extensive intracranial hemorrhages in utero. Because both previous obstetrical histories had gone unrecognized, no preventative strategies had been undertaken. CONCLUSION: Better recognition of this disease through a positive obstetrical history is needed in order to properly counsel patients and institute appropriate prenatal treatment regimens.

Molecular genotyping of fetal platelet antigens with uncultured amniocytes.

OBJECTIVE: Amino acid substitutions in platelet membrane glycoproteins result in alloantigens implicated in neonatal alloimmune thrombocytopenia. We report the use of the reverse dot blot technique to genotype the five major fetal platelet alloantigens from amniotic fluid cells. STUDY DESIGN: We evaluated a patient with Bakb platelet antibodies who had a previous pregnancy complicated by fetal intracranial hemorrhage. The father was heterozygous Baka/Bakb, giving the pregnancy a 50% risk for platelet incompatibility between mother and fetus. Amniotic fluid was obtained at 16 weeks. Deoxyribonuleic acid was extracted from uncultured amniocytes and amplified with polymerase chain reaction. These products were hybridized to filters containing oligonucleotides specific for each of the 10 different platelet antigen alleles. Reactivity was detected with a chromogenic substrate. RESULTS: The reverse dot blot genotyping of uncultured amniocytes revealed the fetus to be Baka/Baka, thus not at risk for neonatal alloimmune thrombocytopenia. CONCLUSION: Precise knowledge of fetal platelet type by amniocentesis could obviate the need for fetal blood sampling and significantly alter prenatal management of neonatal alloimmune thrombocytopenia.

The use of polymerase chain reaction to determine fetal RhD status.

OBJECTIVE: Our purpose was (1) to establish the accuracy of a deoxyribonucleic acid amplification method in determination of RhD status in adult blood samples, including weak D variants (previously referred to as Du) and a D mosaic, and (2) to apply the method to determine fetal RhD status in alloimmunized pregnancies. STUDY DESIGN: Twenty-five adult blood samples, including five weak D variants and one D mosaic, were analyzed with a polymerase chain reaction to determine RhD type. The method was then applied to amniotic fluid samples obtained by amniocentesis from three RhD-negative women with known RhD sensitization. RESULTS: RhD type determined by polymerase chain reaction for all adult blood samples agreed with serologic typing results. All weak D variants and the D mosaic gave results consistent with RhD positivity. Fetal RhD status was determined in each of the three alloimmunized pregnancies, and obstetric management decisions were made on the basis of these results. CONCLUSIONS: This polymerase chain reaction method allows rapid and accurate determinations of fetal RhD status by amniocentesis. Fetal blood sampling or serial amniocenteses may be avoided when the fetus is RhD negative, and plans for surveillance and intervention can be confidently made if the fetus is RhD positive. However, before the widespread use of this assay, its sensitivity and specificity must be established. Because weak D variants and a D mosaic demonstrated RhD-positive status by polymerase chain reaction, the method described is applicable to these RhD variants.

Non palpable breast carcinomas. Histological and immunohistochemical studies of 160 cases.

A series of 160 impalpable breast carcinomas was collected from 1979 to 1991. Mammographs showed microcalcifications (64%), or opaque images (36%). Surgical specimens were X-rayed during the intervention in order (i) to ascertain that the lesions detected on mammographs were removed, and (ii) to guide the pathologist in sampling tissue fragment for an appropriate microscopic evaluation of the lesions. During the intervention, the peroperation histological diagnosis was correct in 63% of the cases, whereas malignancies were underscored in 37%. No false positive diagnosis was recorded. A large majority (92%) of false diagnoses stated during surgery were in situ carcinomas diagnosed as epitheliosis and invasive carcinomas diagnosed as in situ carcinomas. In 63% of the cases the axillary lymph node could be removed during the first intervention. In 91% of the cases "in sano" margins of resection were evaluated as such during the intervention. The size of tumors ranged from 1 to 60 mm (m = 10 mm - SD = 8.45), 70% measuring less than 10 mm. Carcinomas were in situ (23.75%), microinvasive (13.75%) and invasive (62.5%). Carcinomas were ductal (78.1%), lobular (18.7%) and of other types (14.2%). A majority of intraductal carcinoma (68%) were comedocarcinomas. Invasive carcinomas accounted for grade I in 37% of the cases, grade II in 56%, grade III in 7%, ductal carcinomas and for tubular carcinomas in 15%. Immunodetection could be performed on frozen sections in 78 cases. Tumors were receptor positive in 58% of the cases. The greater growth fraction (Ki-67) and higher detection of HER-2/neu oncogene product were observed in comedocarcinomas. Diploid tumors accounted for 52% of those evaluated (n = 48).

[Delivery after 2 previous cesarean sections. A series of 41 uterine trials]. / Accouchement des utérus bicicatriciels. Une série de 41 épreuves utérines.

It has been possible to consider how delivery should be carried out in view of the progress that has been made handling scarred uteruses. Over 21 months 41 tests of uterine function have been authorized in our department out of 67 cases where there were two scars in the uterus (67%). 26 patients delivered vaginally (63.4%) and 5 had Caesarean sections because of failure of the test of the scar. When the relationship between the fetus and the pelvis was satisfactory, the fact that the cervix was not ripe and the presenting part was not engaged, did not prevent carrying out a trial of scar in 78% of cases. It is important to assess conditions continuously during labour and this assessment should include fetal heart monitoring, internal tokometry, fetal pH assessment and ultrasound of the scar at the onset of labour. Oxytocics had to be used in 96.2% of cases because there was at the outset marked dynamic dystocia. Epidural anaesthesia was used in 90.2% of cases. A full obstetric team must be present throughout the whole labour so that the conduct of the labour can be observed, and if necessary corrected quickly if anything in its progress is becoming abnormal. It has become reasonable to carry out tests of uterine scars even after two scars have been made in the uterus because of the absence of any maternal or fetal complications in this series or in the literature.

Inflammatory breast carcinoma: an immunohistochemical study using monoclonal anti-pHER-2/neu, pS2, cathepsin, ER and PR.

Immunocytochemical assays were performed on frozen sections of inflammatory breast carcinomas (n = 22) using the following monoclonal antibodies (MoAb): anti-pHER2/neu, cathepsin, pS2, ER, PR and MoAb Ki67. The distribution of these proteins, known as prognostic indicators, was evaluated with an image analysis system (SAMBA, Alcatel TITN, France). On standard HE stained paraffin sections, only about 50% of inflammatory breast tumors exhibited intradermal tumor cell emboli. All tumors were strongly pHER/2neu positive. All tumors also, but to a lesser degree, were cathepsin and ki67 positive. Conversely, less than 40% were faintly ER, PR and pS2 immunoreactive. The results correlated with the high degree of malignancy of inflammatory breast carcinomas. Therefore the immuno-detection of these markers in addition to standard histological techniques appears to be a useful tool to evaluate the degree of malignancy of breast carcinomas.

[Treatment of urinary stress incontinence by a modified Pereyra procedure:Chrub's operation]. / Traitement de l'incontinence urinaire d'effort par un procédé de Pereyra modifié: l'intervention de Chrub.

The authors report the utility of suspending the cervix by means of the pubo-urethrax ligaments anchored to Cooper's ligaments in treating exercise-related urinary incontinence. A prospective series of 40 female patients gave 97.5% of successful outcomes with regard to the incontinence. The use of the pubo-urethrax ligaments and the absence of subsphincterian dissection confers major urodynamic advantages, particularly with regard to closing pressure. These anatomical and physiological arguments appear to give the procedure an advantage over suspensions using the vagina wall, whether these make use of the upper or lower route. Anchoring to Cooper's ligaments should ensure long-term stability of the outcome.

Inflammatory carcinoma of the breast.

Inflammatory breast carcinoma has to be defined by accurate clinical and pathological criteria. The prognosis is very poor and improvements made by chemotherapy are limited to the increase in the disease-free period and overall survival for a few months.