Association of maternal serum alpha-fetoprotein with persistent placenta previa.

OBJECTIVE: To evaluate the relationship between maternal serum alpha-fetoprotein (MSAFP) and the risk of persistent placenta previa. METHODS: We conducted a retrospective cohort study of singleton pregnancies with sonographic evidence of placenta previa at 15-20 weeks' gestation, between October 1991 and August 2000. Only pregnancies with MSAFP determination at 15-20 weeks' gestation and non-anomalous live-born infants > or =24 weeks' gestation were included. Pregnancies in which Cesarean delivery was performed for placenta previa were considered persistent; this was the primary outcome. RESULTS: Of 275 women with previa at 15-20 weeks' gestation, 33 (12%) had previa at delivery. Trend analysis revealed a greater likelihood of persistent previa with increasing MSAFP values (p=0.01). Mid-trimester MSAFP <1 multiple of the median (MoM) was associated with a decreased incidence of persistence of 4%, significantly less than the risk at > or =1 MoM (16%; p=0.01). CONCLUSIONS: There is an association between increasing MSAFP values and greater likelihood of persistent placenta previa. An MSAFP value <1 MoM is associated with a reduction in the risk of persistence of previa to delivery.

Single uterine axial fast acquisition magnetic resonance fetal survey: is it feasible?

OBJECTIVES: To determine which non-biometric components of the ultrasound fetal survey can routinely be seen on a single fast acquisition magnetic resonance (MR) sequence aligned axial to the maternal uterus. STUDY DESIGN: The non-biometric components of the routine fetal ultrasound examination were applied retrospectively to the initial MR single-shot fast spin-echo acquisition aligned axial to the maternal uterus in the normal fetus to determine whether these parameters could be routinely evaluated. Nineteen women with anatomically normal fetuses had a total of 31 MR studies performed for fetal or maternal indications, either as part of an indicated examination or as part of a study protocol approved by the institutional review board. The images in these 31 MR studies were reviewed by two independent examiners who were blinded to the other's assessment; concordance was necessary for a component to be adequately assessed. The Wilcoxon rank sum test was used to determine the effect of gestational age and fetal lie on the ability to assess non-biometric parameters. RESULTS: Assessment was possible in 85% of the non-biometric parameters. Cord insertion, external genitalia and the four-chamber view of the heart were most problematic. In only two cases was the four-chamber view of the heart identified. Longitudinal lie allowed significantly more parameters (82%) to be evaluated than transverse lie (45%) (p < 0.003). No difference based on gestational age was found. CONCLUSION: A single fast acquisition axial MR sequence can evaluate 85% of the non-biometric components of the fetal ultrasound survey. Fetal lie is an important confounder in the ability to resolve fetal anatomy with a single MR axial uterine acquisition.

A randomized trial that compared oral cefixime and intramuscular ceftriaxone for the treatment of gonorrhea in pregnancy.

OBJECTIVE: The purpose of this study was to evaluate prospectively the Centers for Disease Control recommendations for the treatment of gonococcal infection in pregnancy. STUDY DESIGN: One hundred sixty-one women who were referred with probable endocervical gonorrhea underwent pretreatment endocervical, anal, and oral cultures for Neisseria gonorrhoeae. The women were randomly assigned to receive ceftriaxone 125 mg intramuscularly or cefixime 400 mg orally. Treatment was open and in a 1:1 distribution. There were 95 evaluable patients. The tests of cure cultures were performed 4 to 10 days after treatment. RESULTS: Eighty-six women (91%) had endocervical infection; 39 women (41%) had anal infection, and 11 women (12%) had pharyngeal infection. Fifty of 95 women (53%) had concomitant endocervical chlamydial infection. The overall efficacy was 91 of 95 subjects (95.8%; 95% CI, 89.6%-98.8%). Ceftriaxone was effective in 41 of 43 cases (95%; 95% CI, 84.2%-99.4%), and cefixime was effective in 50 of 52 cases (96%; 95% CI, 86.8%-99.5%). No significant difference was noted in the overall efficacy or by site of infection. Three of the 4 women who experienced treatment failures admitted to unprotected intercourse before their test of cure culture. CONCLUSION: Both intramuscular ceftriaxone 125 mg and oral cefixime 400 mg appear to be effective for the treatment of gonococcal infection in pregnancy.

Immune thrombocytopenic purpura during pregnancy: laparoscopic treatment.

BACKGROUND AND OBJECTIVES: Laparoscopic surgical techniques in pregnancy have been accepted and pose minimal risks to the patient and fetus. We present the first reported case of a pregnant woman with immune thrombocytopenia purpura who underwent laparoscopic splenectomy during the second trimester. METHODS AND RESULTS: The anesthesia, hematology, and obstetrics services closely followed the patient's preoperative and intraoperative courses. After receiving immunization, stress close steroids, and prophylactic antibiotics, she underwent a successful laparoscopic splenectomy. After a short hospital stay, the patient was discharged home. CONCLUSION: Immune thrombocytopenia purpura can be an indication for splenectomy. As demonstrated in appendectomy, cholecystectomy, and our case presentation, laparoscopic splenectomy can be safely performed during pregnancy.

Association between maternal serum alpha-fetoprotein and adverse outcomes in pregnancies with placenta previa.

OBJECTIVE: To determine whether increased maternal serum alpha-fetoprotein (MSAFP) level at 15-20 weeks' gestation is a marker of adverse outcomes in women with placenta previa at delivery. METHODS: We conducted a retrospective cohort study of singleton pregnancies complicated by placenta previa, diagnosed sonographically, and confirmed at delivery. All women had MSAFP screening at 15-20 weeks' gestation and delivered nonanomalous live-born infants at or after 24 weeks' gestation. RESULTS: One hundred seven women with placenta previa delivered during the study. Fourteen (13%, 95% CI 7%, 21%) had MSAFP at least 2.0 multiples of the median (MoM). They were significantly more likely than those with lower MSAFP levels to have one or more of the following outcomes: hospitalization for antepartum bleeding before 30 weeks' gestation (50% versus 15%), delivery before 30 weeks' gestation (29% versus 5%), or preterm delivery for pregnancy-associated hypertension before 34 weeks' gestation (14% versus none). The MSAFP cutoff of 2.0 MoM provided the best combination of sensitivity and specificity for those outcomes, using receiver operating characteristic curves. CONCLUSION: Women with placenta previa who also have high MSAFP levels are at increased risk of bleeding in the early third trimester and preterm birth. We did not find women who required cesarean hysterectomy, including those with placenta accreta, to consistently have elevated MSAFP.

Pregnancy outcomes after antepartum diagnosis of oligohydramnios at or beyond 34 weeks' gestation.

OBJECTIVE: Our purpose was to assess whether antepartum oligohydramnios is associated with adverse perinatal outcomes. STUDY DESIGN: Women delivered between July 1, 1991, and September 30, 1996, who underwent ultrasonography at >/=34 weeks' gestation were analyzed. Oligohydramnios was defined as an amniotic fluid index 50 mm. RESULTS: In our analysis of 6423 pregnancies, 147 (2.3%) were complicated by oligohydramnios. This complication was associated with increased labor induction (42% vs 18%; P <.001), stillbirth (1. 4% vs 0.3%; P <.03), nonreassuring fetal heart rate (48% vs 39%; P <. 03), admission to the neonatal intensive care nursery (7% vs 2%; P <. 001), meconium aspiration syndrome (1% vs 0.1%; P <.001), and neonatal death (5% vs 0.3%; P <.001). CONCLUSION: Antepartum oligohydramnios is associated with increased perinatal morbidity and mortality.

Risk of hepatitis B transmission after amniocentesis in chronic hepatitis B carriers.

OBJECTIVE: To measure the risk of perinatal transmission of HBV in chronic carriers who undergo amniocentesis. METHODS: This was a prospective, longitudinal study from 1990 to 1995 of women who were HBV carriers and underwent amniocentesis. The infants of these women were followed from birth to one year of age. Maternal data examined included HBV antigen and antibody status, liver function tests (LFTs) and the amniocentesis report. RESULTS: Twenty-eight women were identified. Two of 28 neonates were stillborn unrelated to hepatitis. Five infants were lost to follow-up leaving 21 mother-child pairs to evaluate. All 21 women were chronic HBV carriers at the time of amniocentesis for delivery. No mother had abnormal LFTs, and only one of 21 women was positive for hepatitis B e antigen (HBeAg). Thirteen amniocenteses were for advanced maternal age, and four were for abnormal maternal serum alphafetoprotein (MSAFP) screening. None of the amniocenteses were recorded as bloody, and the placenta was anterior in 6 of 21 procedures. None of the 21 infants (95% CI: 0-16.8%) were positive for HbsAg during the first month of life or at 12 months of age. All infants received HBV vaccine and HBIG immunoprophylaxis. CONCLUSION: The risk of transmission of HBV to the fetus after amniocentesis in women who are HBV carriers is low. Immunoprophylaxis in these infants was successful.

Ultrasonographic prediction of fetal outcome in suspected skeletal dysplasias with use of the femur length-to-abdominal circumference ratio.

OBJECTIVE: Our purpose was to determine whether the femur length-to-abdominal circumference ratio can be used antenatally to predict a lethal skeletal dysplasia. STUDY DESIGN: All obstetric sonograms performed from January 1990 to October 1995 were reviewed (44,020 studies) to find those scans suggestive of a skeletal dysplasia. Thirty patients were identified. The femur length/abdominal circumference ratio was then calculated from each patient's initial and subsequent sonograms. Birth outcomes were obtained on the 27 patients who elected to continue their pregnancies. RESULTS: All fetuses with a lethal skeletal dysplasia (n = 12) had a ratio <0.16. The fetuses with a nonlethal dysplasia (n = 8) had ratios between 0.134 and 0.193, with only 1 fetus with a ratio <0.16. All fetuses with no evidence of a skeletal dysplasia after birth (n = 7) had femur length/abdominal circumference ratios >0.18. The 1 fetus with a ratio <0.16 who survived the neonatal period had extreme bowing and demonstrates the limitation of the ratio when bowing is present. CONCLUSIONS: A stillbirth or neonatal death occurred in 12 of 13 patients with a femur length/abdominal circumference ratio <0.16, independent of gestational age. Conversely, no fetus with a ratio >0.16 was found to have a lethal skeletal dysplasia. This information may be useful in counseling women when ultrasonography suggests the diagnosis of a skeletal dysplasia.

Outcome of twin gestations with a single anomalous fetus.

OBJECTIVE: Our goal was to determine whether the presence of one anomalous fetus in a twin gestation affects pregnancy outcome when compared with twin pregnancies without fetal anomalies. STUDY DESIGN: Maternal and neonatal data from 970 twin pregnancies delivered from 1988 to 1995 were collected. Three groups of twin gestations were identified: one fetus with a major anomaly (n = 18), one fetus with a minor anomaly (n = 38), and both fetuses without anomalies (n = 914). RESULTS: Maternal demographic characteristics (age, race, and antepartum complications) were similar among the groups. There was no difference in neonatal outcome (gestational age at delivery, birth weight, cord pH, sepsis, and death) in the minor anomaly and no anomaly groups. There were significant differences between the major anomaly group and the no anomaly group in gestational age at delivery (32.9 vs 35.6 weeks, p < 0.05), birth weight at delivery (1759 vs 2291 gm, p < 0.05), hospital days (41 vs 13 days, p < 0.05), and perinatal death of the anomalous fetus (278/1000 vs 10/1000). Except for total days in the hospital, there was no difference in neonatal morbidity or mortality for the normal fetus when compared with the minor group or the no anomaly group. CONCLUSION: The presence of a fetus with a major anomaly in a twin gestation increases the risk of preterm delivery. The neonatal outcome of the nonanomalous fetus does not appear to be affected by the anomalous fetus.

Autopsy, radiographic, and prenatal ultrasonographic examination of a stillborn fetus with femoral facial syndrome.

Femoral facial syndrome (FFS) is comprised of cleft palate, micrognathia, short or absent femora, and vertebral and genitourinary malformations. We report on a stillborn fetus with FFS delivered to a mother with gestational diabetes. Prenatal ultrasound examination showed abnormalities at 21 weeks of gestation; prior ultrasound findings were interpreted as normal. Long bone histology showed disorganization of the growth plate with a relative decrease in cartilaginous matrix and vacuolization and binucleation of the chondrocytes.

MURCS association: ultrasonographic findings and pathologic correlation.

MURCS association is a rare, lethal and unusual constellation of nonrandom findings that includes mullerian duct aplasia, renal aplasia, and cervicothoracic somite dysplasia.1-3 It has been described in 30 patients by Duncan and coworkers2 in 1979, in which report the authors proposed an embryologic cause for these defects.3 Antenatal ultrasonographic findings included a massive, cystic umbilical cord related to a patent urachus, enlarged bladder, single small kidney, and suspicion of urethral obstruction in a fetus of female phenotype. These findings are rare in a case of MURCS and were all confirmed on pathologic examination.

Acute obstructive hydrocephalus due to cysticercosis during pregnancy.

BACKGROUND: Cysticercosis, due to the parasite Taenia solium, can involve any organ. When central nervous system infection occurs, signs and symptoms depend on the location of the cerebral lesions. Most patients develop seizures, focal symptoms, or headaches with nausea and vomiting. CASE: A case of extraparenchymal (intraventricular) cysticercosis was diagnosed in a patient at term who presented with acute alteration in mental status. Ventriculostomy was performed because of acute obstructive hydrocephalus. Labor ensued and was augmented with oxytocin. Intrapartum management included magnesium sulfate seizure prophylaxis and corticosteroids. Intracranial pressures ranged between 4 and 12 cm H2O peripartum with approximately 300 mL of cerebrospinal fluid drained over the first 24 hours. Postpartum management included craniotomy with resection of a larval cyst and oral praziquantel therapy. CONCLUSION: This case describes an uncommon presentation of neurocysticercosis that should be considered in gravidas with acute mental status changes.

Early repair of episiotomy dehiscence associated with infection.

OBJECTIVE: The purpose of our study was to examine early repair of episiotomy dehiscences in a large urban hospital setting serving a predominantly indigent population. STUDY DESIGN: Since September 1, 1989, we have proceeded with early repair in the immediate postpartum period. The medical records of 34 of 35 patients who underwent early repair were reviewed. RESULTS: Of the 34 patients, 21 (62%) had midline and 13 (38%) had mediolateral episiotomies. Dehiscence was associated with episiotomy infection in 27 (79%) of the 34 patients: 18 (86%) in the midline group and 9 (69%) in the mediolateral group. Repair was accomplished from 3 to 13 days (mean = 6.4) after dehiscence. Successful repairs were accomplished in 32 (94%) of 34 patients. Two (6%) patients with initial third-degree episiotomies had a subsequent breakdown of their repairs and were allowed to heal by secondary intention. CONCLUSIONS: Although most dehiscences in our population were associated with infection, early repair in this population is associated with a satisfactory outcome in the vast majority.