Preconceptional counseling and intervention continued.
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Aspirin↗
Biomedical subjects
J A Kuller
Publications and source records attributed to J A Kuller.
Successful treatment of a cervical pregnancy with a single low dose methotrexate regimen.
Until very recently cervical pregnancies have been treated with surgery, usually hysterectomy. The development of endovaginal ultrasound, which allows early diagnosis, and methotrexate chemotherapy have opened up new therapeutic options. A 45-year-old multigravida presented at 8 weeks' gestation with vaginal bleeding. Endovaginal ultrasound demonstrated a cervical pregnancy with a fetal pole, 1.2 x 1.4 cm sac, no cardiac pulsations, and an empty uterus. After discussion with the patient, single low dose methotrexate 1.5 mg/m2 was given intramuscularly. The patient's hCG titre was 5882 IU-(Third International Standard). Over a 5-week period the hCG titres fell, and the gestational sac disappeared. The patient experienced intermittent vaginal bleeding and cramping but was managed as an outpatient. Single low dose methotrexate may be a successful management option in selected cases of cervical pregnancy.
Cervix Uteri↗
Prenatal diagnosis and management of massive bilateral axillary cystic lymphangioma.
BACKGROUND: Fetal lymphangiomas can occur in many different anatomic locations, including the most commonly seen nuchal cystic hygroma. CASE: A fetus at 18 weeks' gestation was found to have a massive right axillary hygroma. The fetal karyotype was normal. Serial ultrasound examinations indicated progressive enlargement, but no hydrops. At 32 weeks' gestation, a left axillary hygroma was also diagnosed. The patient underwent cesarean delivery. CONCLUSION: Prenatal diagnosis of nuchal cystic hygromas has a high association with karyotypic abnormalities, hydrops, and fetal demise; however, this association may not apply to cystic lymphangiomas at other locations.
Adult↗
Porencephaly secondary to fetal trauma during amniocentesis.
BACKGROUND: There has been one reported case of porencephaly diagnosed postnatally as a result of amniocentesis. We report the first antenatal diagnosis of porencephaly, which apparently resulted from penetration of the fetal skull during amniocentesis. CASE: A 37-year-old woman had genetic amniocentesis at 16 weeks' gestation. The fetal skull was penetrated during the unguided procedure. Porencephaly discovered at 28 weeks' gestation was confirmed by imaging studies in the neonatal period. CONCLUSION: Inadvertent fetal skull penetration appeared to result from amniocentesis unguided by continuous ultrasound.
Adult↗
Non-immune hydrops after 20 weeks' gestation: review of 10 years' experience with suggestions for management.
OBJECTIVE: To analyze the etiologies and outcomes for a southeastern section of the United States, and to organize an efficient approach to evaluation. METHODS: We reviewed 82 cases of non-immune hydrops presenting after 20 weeks' gestation over a 10-year period. RESULTS: Overall perinatal mortality was 86.6%. Fetuses diagnosed with hydrops before 24 weeks' gestation had a perinatal mortality of 95%, with nearly one-third having abnormal karyotypes. The etiology of hydrops diagnosed after 24 weeks' gestation was more likely to remain idiopathic or to be related to cardiothoracic abnormalities. CONCLUSION: Before 24 weeks' gestation, the high risk of mortality and abnormal karyotype justifies offering families funipuncture in the hope of finding a treatable cause of non-immune hydrops. After 24 weeks' gestation, when fewer abnormal karyotypes are found, funipuncture may also be pivotal in diagnosing the cause of non-immune hydrops.
Adult↗
Cesarean delivery: a reconsideration of terminology.
The terminology we employ influences our perceptions. Thus, we believe in reviewing terminology regularly. The term "cesarean section" should be abandoned. A medical procedure is rarely named after a historic figure, and almost never after an ancient Roman law. Cesarean section has recently been amended to cesarean birth; however, the term is still inadequate. The word "hysterotomy" more appropriately describes the procedure we regularly perform. The adjectives used to describe cesarean birth should also be reevaluated. If we are to keep the term "classical" for the original fundal vertical uterine incision, then the other designations of hysterotomy should retain the same architectural context. Contemporary hysterotomy should be used in reference to a low transverse cesarean. Neoclassical hysterotomy might be used to describe the low vertical procedure. Transitional hysterotomy may be an appropriate term for the "hockey stick" or "J" incision. Cesarean delivery best describes a postmortem cesarean. Vaginal birth after cesarean (VBAC) is inappropriate because a vaginal birth after a cesarean section would not occur if cesarean section refers to a perimortem procedure. Vaginal birth after hysterotomy should be substituted for VBAC. Such revision of our terminology will keep obstetrics at the forefront of medical science and bring us most efficiently into the 21st century.
Cesarean Section↗
Outcome of pregnancies with elevation of both maternal serum alpha-fetoprotein and human chorionic gonadotropin.
We evaluated the pregnancy outcome of all patients with elevations of both maternal serum alpha-fetoprotein and human chorionic gonadotropin since institution of combined serum screening at our program. After analysis of 34,404 samples, 99 patients were found to have significant elevations of both maternal serum alpha-fetoprotein and human chorionic gonadotropin. The ultrasound findings, amniocentesis results, and pregnancy outcomes were determined in each case. Sixty-six patients with singleton gestations met entry criteria. Pregnancy outcome information is available for 63 of these patients, 60% of whom had at least one complication. Thirty-three patients with multiple gestations met inclusion criteria. Pregnancy outcome information is available for 31 of these, 81% of whom had at least one complication. These patients had a high incidence of pregnancy related complications. This group would appear to be at higher risk than women with elevation of either maternal serum alpha-fetoprotein or human chorionic gonadotropin alone.
Amniocentesis↗
Alpha 1-antitrypsin deficiency and pregnancy.
Alpha1-antitrypsin deficiency is an inherited pulmonary disorder which results from a deficiency of a major plasma protease inhibitor. The onset and severity of symptoms vary widely and depend on the genotype and whether the patient smokes cigarettes. Alpha1-antitrypsin in pregnancy has only been previously reported twice. Our patient had a functional serum alpha1-antitrypsin level which was 15% of normal but was clinically asymptomatic and she did not smoke. Her genotype revealed a non-ZZ pattern. Her obstetric history was complicated by preterm labor in each of her five ongoing pregnancies. Alpha1-antitrypsin deficiency is inherited via two codominant autosomal genes. Although there is great variability in severity of disease, seriously affected patients may have emphysema and hepatic abnormalities. Patients with non-ZZ genotypes or who are heterozygotes may have favorable pregnancy outcomes.
Adult↗
Myocardial infarction and coronary artery dissection in pregnancy.
Myocardial infarction associated with pregnancy is a relatively rare event, usually related to maternal risk factors for ischemic heart disease such as hypertension and diabetes mellitus. Coronary artery dissection represents an even more uncommon event and generally occurs in peripartum women without predisposing risk factors. A 31-year-old patient's postpartum course was complicated by the development of probable acute fatty liver of pregnancy followed by myocardial infarction and coronary artery dissection. The acute fatty liver of pregnancy and the cardiac event in our patient may both be vasospastic events related to vascular hypersensitivity.
Adult↗
Bacterial vaginosis in pregnancy: an approach for the 1990s.
It is proposed that clinicians screen all pregnant women at high risk for preterm labor and premature rupture of membranes for bacterial vaginosis, and treat all women when it is diagnosed. This infection is associated with a two to three times increase in preterm labor and delivery, premature rupture of the membranes, and endometritis. Although cause and effect have not been conclusively documented, these associations must be considered in the practice of obstetrics at the present. The paucity of vaginal Lactobacillus spp is pivotal in allowing overgrowth of many other organisms of the vagina. Screening is suggested because 50 percent of bacterial vaginosis is asymptomatic. The diagnosis, which is rapidly made and inexpensive, remains defined by clue cells seen on wet prep, high vaginal pH, and amine odor of the vaginal discharge. Optimal treatment of pregnant women with bacterial vaginosis is via oral or intravaginal metronidazole or clindamycin.
Clindamycin↗
Fetal porencephaly: a review of etiology, diagnosis, and prognosis.
Porencephaly may result from either a developmental anomaly or an antepartum intraparenchymal insult. Pre- and postnatal ultrasonography can demonstrate characteristic images of porencephaly. There is minimal literature on diagnosis and outcome of antenatally diagnosed porencephaly. There are two types of porencephaly: type I is generally due to an antepartum intraparenchymal hemorrhage. Type II lesions are usually developmental anomalies. Prognosis generally depends on the extent of the lesion.
Brain Diseases↗
Pregnancy complicated by Guillain-Barré syndrome.
We report a case of a pregnant patient with Guillain-Barré syndrome. Her symptoms, including weakness, vague numbness, urinary incontinence, and unsteady gait, were initially mild and mimicked many of the changes seen in pregnancy. Her progressive weakness was not preceded by any known illness. Evaluation of symptoms revealed an elevated cytomegalovirus IgM titer. When symptoms became severe, electromyography was done, showing a severe demyelinating motor-sensory neuropathy. After plasma exchange and vaginal delivery, symptoms resolved. Neither the patient nor her infant have had any long-term sequelae. Guillain-Barré syndrome may be difficult to diagnose in pregnancy but may be effectively treated with plasmapheresis.
Adult↗
Anatomic changes in the pelvis after uncomplicated vaginal delivery: evaluation with serial MR imaging.
PURPOSE: To demonstrate the normal involution process of the post-partum pelvis with serial magnetic resonance (MR) imaging. MATERIALS AND METHODS: MR imaging was performed in 14 women after uncomplicated vaginal delivery. Six women underwent serial MR examinations at less than 30 hours and at 1 week, 2 weeks, 6 weeks, and 6 months after delivery; eight women were examined only within 30 hours of delivery. The dimensions and signal intensity of the uterus and cervix and the appearance of other pelvic structures were evaluated. RESULTS: The mean length of the uterine corpus was 13.8 cm within 30 hours of delivery and 5.0 cm at 6 months. The mean length of the cervix was 5.6 cm within 30 hours of delivery and 2.9 cm at 6 months. The junctional zone was not visible before 2 weeks; however, it was visible in all cases at 6 months. The outer cervical stroma had high signal intensity less than 30 hours after delivery and intermediate signal intensity thereafter. The inner cervical stroma was visible as a low-signal-intensity stripe on all images. CONCLUSION: Knowledge of the normal MR appearance of the involuting postpartum pelvis provides a baseline for interpretation of MR images obtained during this period.
Adult↗
Contemporary approaches to prenatal diagnosis.
A variety of options for prenatal diagnosis are available to the pregnant woman. Maternal serum analyte analysis, performed between 15 and 20 weeks' gestation, provides a screening test for fetal neural tube defects and aneuploidy in low-risk pregnancies. Fetal ultrasound examination is of benefit in high-risk pregnancies. The necessity of prenatal screening in the low-risk patient with an established date of last menstrual period is more controversial. Ultrasound examination can establish gestational age, assess fetal number and position, determine placental location and amniotic fluid volume, and rule out major structural anomalies. Invasive fetal testing, including amniocentesis and chorionic villus sampling, should be offered to women who are 35 years of age or older or who have had abnormal results on noninvasive prenatal screening and in cases in which the parents are carriers of genetic conditions that are amenable to prenatal diagnosis.
Amniocentesis↗
Varicella during pregnancy. Maternal and fetal effects.
To determine the characteristics of maternal varicella at our institution, we reviewed all cases of primary varicella in pregnancy. Using a perinatal database that summarizes all obstetric admissions, we reviewed the medical records of women with varicella infections during pregnancy. Over a 5 1/2-year period, 31 pregnancies were affected by varicella infection among 11,753 deliveries. The mean age of those patients was 19.6 years, significantly different from our overall population of 25.3 years (P < .05). The racial composition of 35% Hispanic, 35% white, and 29% African American was different from that of our general population of 55% white, 38% African American, and 6% Hispanic (P = .023). The mean gestational age of the eruption of vesicles was 25 weeks. Of the 31 women, 7 had preterm labor within a week of their varicella, 3 delivered prematurely, and 3 infants had a birth weight of less than 2,700 grams. Respiratory symptoms developed in 6 women, and pneumonia developed in 4, 2 of whom required ventilatory support, 1 for 5 days, the other for 49 days. Eight women received acyclovir during gestation, and none suffered sequelae. In all, 6 infants had lesions and anomalies noted at birth, 5 possibly associated with varicella. Varicella infection is associated with a greater-than-expected level of both maternal and fetal morbidity. The fetal disease may occur due to maternal infection at any gestation and is most likely a spectrum of complications. The maternal disease appears to be worse in the latter half of pregnancy. Programs of prevention through vaccination must account for a possibly decreased level of immunity in different populations.
Acyclovir↗
Obstetric damage and faecal incontinence.
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Episiotomy↗
Preconceptional counseling and intervention.
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Female↗
Prenatal diagnosis of renal agenesis in a twin gestation.
Bilateral renal agenesis is a lethal congenital anomaly. It appears to be transmitted in a polygenic pattern. The prenatal ultrasound findings consist of severe oligohydramnios, absence of the fetal bladder, and failure to identify fetal kidneys. Twin gestations with renal agenesis have been described in the paediatric literature. We detail a case of a patient with two prior affected pregnancies with bilateral renal agenesis. Her latest pregnancy was diagnosed prenatally, with one fetus with bilateral and the other fetus with unilateral renal agenesis. The ultrasound findings should be differentiated from the stuck twin phenomenon.
Adult↗