Biomedical subjects
Publications and source records attributed to E A Reece.
An example of congenital uterovesical fistula is presented. The cardinal diagnostic feature is monthly painless macroscopic hematuria with onset at menarche. It is possible that a delay in prompt diagnosis and corrective surgery may lead to undesired consequences. The literature has revealed only one other recorded case of the congenital type of uterovesical fistula.
Müllerian duct dysgenesis may result in various genitourinary abnormalities and a high incidence of associated gestational losses. The bicornuate uterus (with either one or two cervices) and a single vagina are the most common genital variations, whereas an ectopic pelvic kidney and unilateral renal agenesis are the most common associated renal malformations. Inspite of the high incidence of fetal wastage resulting from pregnancies associated with congenital uterine abnormalities, aggressive perinatal and neonatal therapy may improve the gestational outcome.
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A prospective randomized study comparing constant intravenous infusion of regular, low-dose insulin versus conventional subcutaneous administration of neutral protein Hagedorn (NPH) insulin in insulin-requiring patients undergoing orthopedic procedures under general anesthesia was undertaken. The degree of diabetic control was better in those receiving constant 2 units/hour of regular insulin than in those receiving two thirds of daily maintenance doses of NPH insulin. However, in two of eight patients receiving 2 units/hour, decreased insulin infusion rates and increased dextrose infusion rates were required to avoid hypoglycemia. Preoperative NPH insulin and 1 unit/hour insulin administration resulted in equivalent diabetic control.
It has been reported that the congenital anomalies frequently observed in offspring of diabetic women may be predicted by first-trimester ultrasound findings that reveal diminution in growth of the embryo/fetus. The aim of the current study was to examine the relationship between early growth delay and congenital anomalies in pregnancies complicated by diabetes. We conducted a retrospective study of 38 patients with insulin-requiring pregestational diabetes mellitus and 81 control pregnancies who had first-trimester ultrasound examinations. A cross-sectional survey of all patients revealed a congenital anomaly rate of 18.4% among the diabetic pregnancies compared to 4.9% among controls (P < 0.02). Early fetal growth delay was defined as a difference of six or more days between the menstrual gestational age and the sonographic gestational age (menstrual age minus ultrasound age). Early growth delay was exhibited in fifteen control pregnancies (18.5%) and eleven insulin-requiring pregestational diabetic pregnancies (28.9%) (P = 0.02). However the incidence of congenital anomalies in these two groups was significantly different, but there was no difference between groups with and without growth delay. The longitudinal growth of two anomalous fetuses of the diabetic group and three anomalous fetuses from the control group was studied. Both groups of fetuses remained within the normal growth range for their respective groups. This study described herein fails to confirm the association of early fetal growth delay with the occurrence of congenital malformations in insulin-requiring pregestational diabetic pregnancies.
To evaluate maternal-fetal outcomes in pregnancies complicated by diabetic nephropathy were evaluated. Nephropathy was defined as proteinuria of >300 mg/24, or albuminuria >300 mg/24 hr in the absence of infection. Twenty-seven pregnant women with variable degrees of diabetic nephropathy were included in the study. Prenatal care included stringent metabolic control and management of hypertension. Fetal and maternal outcomes were obtained by medical record review. There were no fetal deaths. One neonatal death occurred in a fetus delivered at 29 weeks gestation. IUGR and major congenital malformations were observed in 9% of the neonates; 26% of the infants were delivered preterm. Chronic hypertension (77%) and preeclampsia (53%) were common maternal complications; 63% of women required delivery by cesarean section. Successful pregnancy outcomes were achieved in >95% of the women in our population. Modern management of the pregnancy complicated by diabetes has substantially improved the outcome of class F/FR diabetic mothers and their infants.
Nephropathy is a complication of diabetes mellitus that can affect women in their reproductive years. This article reviews the effects on treatment on the main factors associated with short- and long-term complications in pregnant women with diabetic nephropathy. Tight glycemic control, adequate treatment of elevated blood pressure, and renal function in early pregnancy are the most significant predictors of maternal and perinatal outcomes. Contemporary methods of perinatal care and adequate treatment of blood pressure allow fetal survival rates of 95%. Furthermore, pregnancy per se does not appear to worsen the natural progression to end-stage renal disease for most women with renal insufficiency. However, patients with moderate to severe renal impairment may experience acceleration of renal disease.
OBJECTIVE: To determine whether there is a relationship between birthweight and interval between 1-h and 3-h glucose tolerance test (GTT) as well as other factors. METHODS: We performed a retrospective analysis of our computerized diabetes database for the years 1992-1997. Ninety-four women with gestational diabetes fulfilled the inclusion criteria (i.e., singleton gestation, term delivery, absence of medical conditions, and known interval between 1-h and 3-h GTT). They were evaluated based on prepregnancy body mass index (BMI), mean glucose values, interval between diagnostic testing, and gestational age of 3-h GTT. RESULTS: Subjects with GDM had a mean glucose value of 96.8 mg/dl and average prepregnancy BMI of 29.3 kg/m2. When GDM subjects with and without macrosomic infants were compared, mean glucose values (97.4 vs. 96.6 mg/dl) and mean interval (18.1 vs. 17.0 days) between diagnostic testing did not significantly differ. However, maternal prepregnancy BMI was higher in the group of women who gave birth to macrosomic infants (32.2 vs. 28.22 kg/m2, P = 0.008). Using stepwise multiple regression, maternal prepregnancy BMI was the only variable found to be predictive of macrosomia. CONCLUSION: We were unable to show a statistical relationship between interval of diagnostic testing and rate of macrosomia. However, we demonstrated a clear relationship between maternal BMI and infant birthweight.
OBJECTIVE: To assess the transverse cerebellar diameter (TCD) in preterm and term neonates with normal growth or growth restriction. METHODS: TCD was sonographically measured after birth in 404 neonates born between 23 and 42 weeks of gestation. The study included two groups: Group 1: 334 appropriately grown for gestational age (AGA) neonates (both birthweight (BW) and head circumference (HC) were between the 3rd and 97th centiles), which were subdivided into two subgroups according to the HC measurements. Group 2: 70 small for gestational age (SGA) neonates (BW <3rd centile), were further divided into three subgroups according to HC measurements. RESULTS: In Group 1 of AGA neonates, a linear growth function was observed between the TCD and GA (R = 0.914, P < 0.00001, TCD = 0.279 + 0.142 X GA), and between TCD and HC (R = 0.886, P < 0.00001, TCD = -0.333 + 1.777 X HC). The percentage of neonates with normal TCD (> or =10th centile) was more than 85% of the AGA and asymmetric SGA subgroups, and 60.7% of the microcephalic SGA subgroup (P < 0.02). CONCLUSIONS: This study provides normative data of neonatal TCD across gestational age. TCD measurement via sonography is a new adjunctive criterion for objectively assessing gestational age in infants when a precise determination of gestational age is necessary. This is very important since utility of the TCD is effective for both AGA and asymmetric SGA infants.
Evaluation of a non-isotopic DNA-rRNA hybridization assay [Probe Assay-Chemiluminescence Enhanced System (PACE II, Gen-Probe, San Diego, CA)] for the direct detection of Neisseria gonorrhoeae from clinical specimens was compared with culture. Culture and probe tests were performed on 795 endocervical specimens. Results demonstrated that total positives by culture were 18 (2.3% of total); both culture and the DNA-rRNA assay agreed in all cases but four. The PACE II yielded four hybridization-positive results with negative companion cultures. The sensitivity, specificity, and positive and negative predictive values for PACE II were 100%, 99.5%, and 82%, and 100%, respectively. The four discrepant results were resolved using a competitive nucleic acid hybridization assay with recalculated sensitivity, specificity, and positive and negative predictive values of 100, 99.7, and 91.6 and 100%, respectively. Overall, the DNA-rRNA assay offered a number of advantages over culture. The assay was more rapid, able to be performed directly on clinical specimens, and provided superior transport stability.
OBJECTIVE: The incidence of major congenital malformations is approximately 6-9% in pregnancies complicated by diabetes mellitus. This incidence is 3-4-fold higher than that in the general population. Congenital malformations are now ranked as the leading cause of death in the offspring of women with diabetes. The precise mechanism(s) by which these anomalies are induced is unknown. It is also not clear what predisposes women to deliver malformed infants, which infants are at risk, and why some are spared even when exposed to presumably high risk conditions. The purpose of this report is to determine, from the literature, the primary etiologic factors associated with diabetes-induced embryopathy and its prevention. METHODS: A review of the current literature regarding malformations in diabetic pregnancies was conducted to elucidate dominant concepts in the pathogenic mechanism(s) of these anomalies and to discuss current and future strategies for their prevention. RESULTS: Numerous investigators have demonstrated that hyperglycemia has a teratogenic effect during organogenesis. However, the exact mechanisms involved have not been completely elucidated. Dietary supplementation of deficient substrates (arachidonic acid or myo-inositol), either in vitro or in vivo, has been shown to reduce the incidence of diabetes-related malformations in offspring of diabetic pregnant animals. In addition, free oxygen radical-scavenging enzymes and antioxidants aimed at reducing the excess load of radicals also result in a reduced malformation rate. Clinical evidence has demonstrated that the teratogenic effects of hyperglycemia may be obviated by maintaining euglycemia throughout organogenesis. Numerous studies have demonstrated that participation in a preconception care program can reduce the incidence of malformations in women with diabetes to the background rate. Unfortunately, less than 10% of women with diabetes currently enter these programs. CONCLUSIONS: Diabetic embryopathy remains the single most common lethal problem affecting diabetic pregnancies today. Although preconception planning and glycemic control can reduce the incidence of malformations, it is often difficult to get women to attend such programs and to achieve and maintain euglycemia. The use of dietary supplements, which presumably would override the teratogenic effects of aberrant metabolic fuels, holds great promise for the future as a prophylaxis against diabetic embryopathy.
Needle embroyfetoscopy (NEF) permits direct visualization of the embryo/fetus with a specially designed 16-gauge double-barrel instrument sheath which is passed transabdominally into the amniotic cavity. We report the case of a woman with a MSAFP of 2.5 MOM who had declined amniocentesis. A targeted ultrasound examination of the spine revealed what appeared to be spina bifida in the lumbar sacral segments from L2 to S1. The mother elected to undergo NEF at 15 weeks gestation, which was successfully performed and revealed no evidence of a neural tube defect. NEF has a tremendous potential for both early prenatal diagnosis, and possibly fetal treatment.
A case report is presented herein of a 33-year-old woman with a history of congenital adrenal hyperplasia in 2 prior births. At 30 weeks of gestation, a scan of the fetal perineum demonstrated ambiguous genitalia which was confirmed at birth. This case demonstrates that when the fetal perineum is well visualized, the diagnosis of normal and abnormal genital development can be made sonographically. This can assist in perinatal/neonatal management, planning and in some cases, can also serve as an additional tool to monitor the success of prenatal steroid therapy of fetal congenital adrenal hyperplasia.
Exstrophy of the urinary bladder is a rare congenital malformation. The first case of sonographic diagnosis, prior to viability, of bladder exstrophy without associated anomalies is presented. The diagnosis before viability allowed the parents to receive counseling on prognosis as well as possible options. This case is unique in that the bladder anomaly was an isolated defect, not associated with any other structural anomaly. The literature on the subject is also reviewed.
OBJECTIVE: To demonstrate the efficacy of first-trimester needle embryofetoscopy (or embryoscopy) for prenatal diagnosis in a continuing pregnancy. STUDY DESIGN: A patient at risk for giving birth to an infant with Robert's syndrome was referred for prenatal diagnosis at 12 weeks of gestation. RESULTS: Transabdominal embryoscopy and amniocentesis were performed. Direct visualization of the embryo was achieved and no gross limb or facial abnormalities were seen. Chromosome studies of the amniotic fluid revealed a normal male 46, XY. Special studies with C-banding and DAPI techniques revealed no evidence of premature separation of centromeres. Two- and three-dimensional ultrasound also demonstrated no gross limb or facial abnormalities. CONCLUSIONS: This case confirms the efficacy of embryoscopy as a simple and relatively low-risk approach to first-trimester diagnosis for continuing pregnancies.
OBJECTIVE: The purpose of this article is to examine the role of yolk sac failure during organogenesis in the development of diabetes-associated embryopathy. METHODS: The current literature regarding congenital malformations in diabetic pregnancies was reviewed to elucidate the precise role of the yolk sac in embryonic development and the relation between yolk sac injury and embryopathy. RESULTS: We and others have demonstrated that hyperglycemia produces a teratogenic effect during organogenesis. In addition, we have shown that the yolk sac appears to be the target site of injury induced by hyperglycemia. We have also presented evidence that cell membrane dysfunction leads to failed vitelline vessel formation and that arachidonic acid supplementation prevents many of the morphologic and biochemical alterations observed under hyperglycemic conditions. CONCLUSIONS: These data strongly support the teratogenic effect of hyperglycemia, the arachidonic acid deficiency state, the resultant maldevelopment of vitelline vessels, and the ability to prevent these changes by arachidonic acid supplementation. These studies have made significant inroads in explaining why diabetes-associated anomalies occur, and suggest a potential future role for prophylaxis against these organogenetic malformations using dietary polyunsaturated fatty acid supplementation.