A Case of Unusual Suicide due to Overlapping Inhalation of Nitrous Oxide and Carbon Monoxide / 대한법의학회지

Nitrous oxide (N2O) is a chemical used as a medical anesthetic supplement, industrial semiconductor cleaning agent, and food additive in the manufacture of whipping cream. Nitrous oxide causes hypoxemia and suffocation during repeated inhalation. In severe cases, it causes coma and death. Some of those who are not aware of the dangers still illegally obtain and abuse nitrous oxide even with the law enforcing its use, and some people seem to have abused nitrous oxide after purchasing large amounts in small containers before the law has taken effect. Deaths from misuse of nitrous oxide are extremely rare in South Korea compared to those from other addictions such as carbon monoxide poisoning. No autopsy or follow-up blood tests were performed in this case.However, this is a unique and rare case in which carbon monoxide inhalation due to the combustion of lightning coal at the last moment overlaps with continuous inhalation of large amounts of nitrous oxide for several days beyond simple hallucination use, and is included in this report with a simple literature review.

Prenatal Diagnosis of Accompanying Alveolar Cleft and Cleft Palate in Fetuses with Cleft Lip Using Prenatal 3D Sonographic Identification and Antenatal Counseling

PURPOSE: Cleft lip and/or palate is the most common congenital facial anomaly whose incidence is about 1 in 500~1000 live births. As this anomaly may be associated with the serious chromosomal anomalies or the multiple organ abnormalities resulting in the fetal loss or perinatal maternal morbidity and mortality, careful prenatal counseling with early and accurate detection is important. Although conventional prenatal ultrasound(US) examination in midterm pregnancy has been applied for screening of cleft lip, there are definite limitations in the diagnosis of accompanying cleft palate or alveolar cleft. We applied high-resolution 3D US along the serial axial, coronal and sagittal plane so that we could diagnose the cleft palate and/or alveolar cleft in fetuses with cleft lip. METHODS: From May 2005 to September 2005, 20 fetuses with cleft lip were examined with prenatal 3D US. Average maternal age was 28.8 years old(24-35 years old), and average gestational age was 24.8 weeks(17.6 to 34.2 weeks). Consecutive axial, coronal and sagittal multislice view were obtained via prenatal 3D US examination and diagnosis of cleft palate and/or alveolar cleft in cleft lip fetuses was followed. RESULTS: With noninvasive and safe prenatal 3D US examination, 17 of 20 cleft lip fetuses were demonstrated to have cleft palate and/or alveolar cleft. Prenatal counseling according to the result was made. CONCLUSION: Existing prenatal US examination is suitable for screening the cleft lip fetuses but has limitation in identifying the related existence of cleft palate and/ or alveolar cleft. Authors verify the presence of cleft palate and/or alveolar cleft acquiring the successive multislice axial, coronal, and sagittal view with prenatal 3D US examination. Therefore, prenatal 3D US examination could be regarded as a noninvasive and secure screening modality in fetuses with cleft lip for confirming whether cleft palate and/or alveolar cleft is accompanied.

Analysis of Preterm Birth Rate based on Birth Certificate Data: from 1995 to 2003 / 대한산부인과학회지

OBJECTIVE: This study was performed to evaluate changes in the preterm birth rate and risk factors of preterm birth in Korea. METHODS: A total number of 5,433,746 birth cases from the birth certificate data from 1995 to 2003 obtained from the National Statistical Office of Korea was reviewed and analyzed. We evaluated the annual preterm birth rate for 9 years, seasonal and regional variations, multiple birth rate, the preterm birth rate for women aged 35 years or older. The logistic regression analysis was used to examine the relationship between preterm birth and risk factors including maternal and paternal age, parity, infantile sex, season and region of birth. RESULTS: The preterm birth rate has increased from 4.25% in 1995 to 10.03% in 2003. Seasonal and regional variations were found. The preterm birth rate was 6.65% in spring, 7.75% in summer, 7.36 in autumn, and 7.38% in winter. The preterm birth rate was 5.06% in Jeollabuk-do, the lowest rate, and 9.17% in Ulsan, the highest rate in Korea. The multiple birth rate has increased from 1.32% in 1995 to 2.01% in 2003. The mean age at first birth was 26 years in 1995, 28 years in 2003, and first birth rate for women aged 35 years or older has increased from 2.4% in 1995 to 4.8% in 2003. The preterm birth rate for women aged 35 years or older also increased from 8.14% in 1995 to 14.74% in 2003. The risk for preterm birth was significantly higher in the women aged 35 years or older, compared with those under 35 years (OR: 1.572, p<0.001). The risk for preterm birth in father aged 40-70 years was higher than those under 30 years (OR: 1.316, p<0.001). In the order of birth, the risk was higher in second or more-born than first-born (OR: 1.122, p<0.001). The odds ratio of preterm birth by infantile sex was 0.84 in male (p<0.001). Risk was significantly higher in multiple birth than in singleton (OR: 20.078, p<0.001). CONCLUSION: Based on the birth certificate data from 1995 to 2003, the preterm birth rate in Korea has increased since 1995. Older maternal and paternal old age, multiparity, male infant, and multiple birth can be considered as risk factors for preterm birth.

Clinical outcome of prenatally diagnosed isolated fetal ventriculomegaly: retrospective analysis of 175 cases / 대한산부인과학회지

OBJECTIVE: The objective of this study is to evaluate the natural course, postnatal outcome, and association between the degree of ventriculomegaly and neurodevelopmental delay in isolated fetal ventriculomegaly. METHODS: We reviewed the medical records of pregnant women diagnosed with isolated fetal ventriculomegaly from October 1996 to June 2004. We defined mild ventriculomegaly as atrial width of 10-14.9 mm and overt ventriculomegaly as 15 mm or more. Neonatal brain ultrasonography was performed in all cases and brain MRI was performed as necessary. Neurodevelopmental outcome was evaluated by medical records and telephone interviews. We analyzed the final outcome of isolated fetal ventriculomegaly according to the ventricular width. RESULTS: There were 175 cases of isolated fetal ventriculomegaly, with a large proportion of male fetuses (68.6%), and one case of trisomy 21. While the group with prenatally resolved ventriculomegaly (n=119) had a smaller ventricular width and more unilaterality, there was no resolution in cases with a ventricular width of 15 mm or more. One hundred and thirty one fetuses with an initial ventricular width of 10 to 11.9 mm had no developmental delay, however, there were 2 cases of cerebral palsy and 2 cases of genetic disorder. Seventeen fetuses had ventricular dilatation of 15 mm or more, with 6 corresponding cases of developmental delay and one case of cerebral palsy. CONCLUSION: Among isolated fetal ventriculomegaly, mild, unilateral or stable ventriculomegaly seems to have a favorable neurological outcome, especially those cases with ventricular width of less than 12 mm. However, management of the condition and counseling of parents are still crucial, because it can be a marker of genetic disorder or brain developmental delay.

Clinical evaluation of In-utero fetal shunt operation using basket-shaped catheter: 5-year experience at Asan Medical Center / 대한산부인과학회지

OBJECTIVE: To evaluate the clinical outcomes of In-utero fetal shunt operations at Asan Medical Center. METHODS: We reviewed the medical records of 33 occasions in 28 pregnancies that underwent intrauterine shunt operations between December, 1998 and April, 2004. Fetal shunt operations were considered for cases of hydrothorax (N=10), congenital cystic adenomatoid malformation type I (CCAM Type I)(N=5), lower urinary tract obstruction (N=6), severe hydronephrosis (N=7) and severe fetal ascites (N=5). Selection criteria of fetus for the shunt operation required normal karyotype and negative infection. Basket-shaped catheter was used for the procedure. Kruskal-Wallis test, Mann-Whitney U test, and Chi-Square test were used for statistical analysis. P<0.05 was considered statistically significant. RESULTS: In CCAM Type I, the mean gestational age was 25.6+/-4.0 weeks at diagnosis, 26.0+/-4.4 weeks at shunt operation and 36.6+/-3.9 weeks at delivery. Perinatal survival rate was 66.7% (2/3). In hydrothorax, the mean gestational age was 26.7+/-3.3 weeks at diagnosis, 27.3+/-3.3 weeks at shunt operation and 34.9+/-3.0 weeks at delivery. Perinatal survival rate was 80.0% (4/5). In lower urinary tract obstruction, the mean gestational age was 18.5+/-3.7 weeks at diagnosis, 19.6+/-3.5 weeks at shunt operation and 34.5+/-2.9 weeks at delivery. Perinatal survival rate was 80.0% (2/3). In hydronephrosis, the mean gestational age was 25.3+/-5.3 weeks at diagnosis, 27.4+/-5.3 weeks at shunt operation and 36.9+/-2.2 weeks at delivery. Perinatal survival rate was 83.3% (5/6). In ascites, the mean gestational age was 29.6+/-3.9 weeks at diagnosis, 29.9+/-3.8 weeks at shunt operation and 34.1+/-3.0 weeks at delivery. Perinatal survival rate was 100.0% (5/5). Complications occurred in 48.5% (16/33) of the cases. The most common complication was shunt dislodgement (N=7). CONCLUSION: In-utero fetal shunt operation should be considered as a treatment option for hydrothorax, CCAM type I, lower urinary tract obstruction, severe hydronephrosis and severe ascites with a significant risk for pulmonary hypoplasia.

Prenatal ultrasonographic findings of a case of multiple pterygium syndrome / 대한산부인과학회지

Multiple pterygium syndrome is an inherited condition characterized by joint pterygium and flexion contracture, in association with other abnormalities such as fetal hydrops, cystic hygroma, club foot, intrauterine growth retardation and hypoplastic lungs. It is usually inherited as an autosomal recessive trait, although X-linked recessive inheritance is also reported. The pathogenesis has been suggested to be early onset fetal akinesia, fragile collagen or generalized edema. Prenatal diagnosis of multiple pterygium syndrome is possible by demonstrating severe limb contractures, absence of fetal limb motion and progressive fetal edema in mid-pregnancy, but in case with a family history of this syndrome, ultrasound studies should be started in the first trimester. We have experienced a multiple pterygium syndrome with a history of recurrent fetal hydrops, so report on the prenatal sonographic findings of this case with brief review of literatures.

Clinical significance of fetal nuchal translucency during early pregnancy / 대한산부인과학회지

OBJECTIVE: To examine the significance of fetal nuchal translucency during early pregnancy in detection of chromosomal abnormality and major cardiac defect METHODS: Between Jul 1998 and Jul 2002, ultrasound examination was performed in 1,253 unselected singleton pregnancies with a live fetus and fetal crown rump length of 24-88 mm. The fetal nuchal translucency thickness was measured successfully in all cases. We reviewed the pregnancy outcome about two parameters. Chromosomal abnormality was confirmed by antenatal karyotyping and newborn's feature suggestive of a chromosomal defect. Major cardiac defect was confirmed by newborn physical examination, targeted ultrasonography, neonatal echocardiography and autopsy. RESULTS: (1) Fetal nuchal translucency thickness increased significantly with crown-rump length. (2) Nuchal translucency was greater than 3 mm in 12 pregnancies with abnormal karyotypes, giving a detection rate of 75.0% with a false positive rate of 4.0%. With a cutoff of 2.5 mm, a detection rate of abnormal karyotype was 81.3% with a false positive rate of 8.3%. And with a gestational age specific cutoff, 95 percentile, a detection rate of abnormal karyotype was 75%, with a false positive rate of 6.4%. (3) With normal karyotype, the overall prevalence of major cardiac defects in this study population was 5/1,000 pregnancies (5/1,054). This prevalence increased from 48/1,000 (4/83) using 2.5 mm cutoff to 105/1,000 (4/38) using 3 mm cutoff. The detection rate for major cardiac defect of nuchal translucency above 3 mm is 80.0% with a false positive rate of 3.2%. CONCLUSION: Increased nuchal translucency is by far an important and efficient marker for screening of chromosomal defects and effective screening method for major cardiac defects.

Randomized comparison of vaginal prostaglandin E2 pessary with vaginal prostaglandin E2 tablet for the induction of labor / 대한산부인과학회지

OBJECTIVE: To compare the efficacy and the safety of two standardized preparations of vaginal prostaglandin E2 pessary (PGE2 pessary) and vaginal prostaglandin E2 tablet (PGE2 tablet) for the induction of labor. METHODS: Pregnant women who were hospitalized for the induction of labor from December 2002 to June 2004 at the Asan Medical Center were included for the prospective randomized study. Subjects were randomly assigned to receive PGE2 pessary or PGE2 tablet as a cervical ripening agent. A successful outcome was defined as a change in Bishop score of >or=3, Bishop score of >or=6 at 12 hours, or vaginal delivery after the insert placement. RESULTS: One hundred ninety-seven women (PGE2 pessary, 99 women; PGE2 tablet, 98 women) completed the protocol. There were no statistically significant differences between the two groups in terms of a successful outcome (85.9% vs 84.7%; p=0.952) and the following mean times: (1) time to active labor (851 vs 751 minutes; p=0.207), (2) time to vaginal delivery (1024 vs 873 minutes; p=0.091). However, in parous women the labor time interval was shorter in PGE2 tablet group. In addition, no differences were observed in the incidences of cesarean delivery, hyperstimulation syndrome, abnormal fetal heart rate patterns, and adverse neonatal outcomes. CONCLUSION: Both PGE2 preparations were equally effective in achieving cervical ripening, initiating labor, and achieving a successful vaginal delivery. However, the vaginal PGE2 pessary may offer the advantage of prompt removal when it is required.

Abnormal Prenatal Sonographic findings in Two Cases of Zellweger Syndrome / 대한주산의학회잡지

Zellweger syndrome is a lethal autosomal recessive disorder characterized by neonatal hypotonia, neonatal seizure, psychomotor retardation, facial dysmorphism, and hepatomegaly. It is characterized by an absence or marked decrease of the number of peroxisomes. Children with Zellweger syndrome rarely survive their first year of life. Diagnosis depends on demonstration of elevated very long chain fatty acid in plasma and deficient activity of the peroxisomal enzyme. Chorionic villi sampling or the biochemical analysis of amniocytes makes it possible to identify a fetus affected by Zellweger syndrome during the first trimester of pregnancy. We experienced two cases of postnatally diagnosed Zellweger syndrome with mild sonographic abnormalities prenatally and report our cases with a brief review of literature.

Tachyarrhythmia:Prenatal Diagnosis, Management and Perinatal Outcome / 대한주산의학회잡지

OBJECTIVE: To review the diagnosis, treatment, and perinatal outcome of fetal tachyarrhythmias. METHODS: We reviewed the medical records of pregnant women diagnosed with fetal tachyarrhythmia at Asan Medical Center from June 1997 to December 2004. Tachyarrhythmias were classified as either supraventricular tachycardia (SVT) or atrial flutter (AF), and the intrauterine management and long-term outcomes of the infants were analyzed. RESULTS: There were three cases of SVT and four cases of AF. Fetal hydrops was noted in 4 of 7 fetuses and there were no cardiac anomalies. All of them were treated in utero with antiarrhythmic agents including digoxin and flecainide. During antiarrhythmic therapy, sinus rhythm was achieved in 100% of them and the survival rate was 100%. Two infants diagnosed prenatally with SVT developed Wolff-Parkinson-White syndrome after birth. One of them developed paroxysmal SVT but after adenosine treatment she needed no treatment. One fetus with AF was diagnosed with an atrial ectopic tachyarrhythmia postnatally which needed medication for one year and resulted in normal sinus rhythm. At the time of this study, all of them showed normal development without neurological morbidity. CONCLUSION: Fetal tachyarrhythmias diagnosed prenatally can be effectively treated with antiarrhythmic drugs in utero or postnatally even if they had hydropic feature. So they must be referred to a tertiary care center for appropriate counseling and management. We recommend that every SVT or AF should be treated in utero regardless of the presence of hydrops.

Two Cases of Prenatal Diagnosis of 22q11.2 Deletion Syndrome (DiGeorge Syndrome) / 대한산부인과학회잡지

Before the exact location of its chromosomal abnormality was identified, 22q11.2 deletion syndrome was described as many different names depending on its presenting clinical features. Patients with this syndrome have a wide range of findings such as cardiac anomaly, abnormal face, thymic hypoplasia, cleft palate, and hypocalcemia. Cardiac involvement is a prominent feature and most of the patients have a conotruncal heart defect. 22q11.2 deletion is the most common chromosomal cause of congenital heart defect after trisomy 21. Familial transmission accounts for about 8 per cent of cases and most of the cases develop sporadically. Even in cases where this syndrome is inherited, the parents' chromosomal abnormalities are often discovered only after the deletion is suspected in their children. We describe two prenatal cases in which this syndrome was suspected by ultrasonogram and confirmed by fluorescent in situ hybridization (FISH). In both cases, there was no known prior family history of cardiac abnormalities or chromosomal abnormality. In one case, autopsy following termination further confirmed the diagnosis. In the other case, the mother was also found to have 22q11.2 deletion.

Applicable Indications and Effectiveness of the Selective Arterial Embolization in the Management of Obstetrical Hemorrhage / 대한산부인과학회잡지

OBJECTIVE: To describe the angiographic embolization as a safe and an effective alternative treatment in the management of obstetrical hemorrhage and in preserving fertility. METHODS: Between March 1999 and May 2003, 43 patients at Asan Medical Center underwent angiographic embolization for the management of obstetrical hemorrhage. All cases received arterial embolization because of obstetrical hemorrhage unresponsive to conservative management or prophylaxis for massive obstetrical hemorrhage. Medical records were reviewed and detailed to collect adequate clinical data such as clinical status, underlying conditions, amount of transfusion, embolization sites, materials of embolization, duration of the procedure, complications associated with embolization, hospital stay, and the success rate. Patients were contacted by telephone to obtain long-term outcome for menstruation, desire for conception, and subsequent pregnancies. RESULTS: We have experienced the clinical successful embolization in 37 (86.0%) of 43 patients of obstetrical hemorrhage resulting from various causes. The main cause of hemorrhage was atony of uterus (n=17), followed by abnormal placentation (n=6), genital tract laceration (n=5). The average amount of blood transfusion was 7.0 units (range; 0-36 units). The average length of the time for the procedure was 68.2 minutes (range; 30-150 minutes). The average duration of hospitalization was 6.4 days (range; 3-20 days). The main complication after embolization was numbness and pain on right lower extremities in 5 cases and vessel dissection occurred in 1 case. But there was no major complication related to the procedure. We were able to follow up 28 patients. In all cases menses resumed spontaneously soon after the procedure. Seven cases of long-term follow-up became pregnant, and 3 cases of them completed gestations giving birth to healthy babies. CONCLUSION: The results suggest that angiographic embolization is a relatively noninvasive and highly effective method for the management of obstetrical hemorrhage and a useful technique for preserving fertility.

Clinical efficacy of urgent cerclage in cervical incompetence predicted by transvaginal ultrasonography in second trimester / 대한산부인과학회잡지

OBJECTIVE: To investigate the clinical efficacy of urgent cerclage on perinatal outcome in cervical incompetence predicted by transvaginal ultrasonography in second trimester. METHODS: We reviewed the medical records of 27 pregnant women who received urgent cerclage at Asan Medical Center between January, 1998 and August, 2002. When the cervical length was less than 25 mm and abnormal cervical shape by transvaginal ultrasonography in second trimester, we performed urgent cerclage. Abnormal cervical shapes were categorized as U-shape, Y-shape and V-shape. These data were compared with those of 102 patients who received prophylactic cerclage and 25 patients who received emergent cerclage during the same period. Analysis of variance and chi-square test were used for statistical analysis. P<0.05 was considered statistically significant. RESULTS: In urgent cerclage, the mean gestational age at delivery was 35.1 +/- 4.4 weeks. The mean birth weight was 2524.2 +/- 860.8 gm and perinatal survival rate was 92.6% (25/27). We compared these data with the other two cerclages. In prophylactic cerclage, the mean gestational age at delivery was 36.2 +/- 4.6 weeks. The mean birth weight was 2711.5 +/- 860.8 gm and perinatal survival rate was 94.1% (96/102). There was no statistically significant difference between urgent cerclage and prophylactic cerclage. In emergent cerclage, the mean gestational age at delivery was 27.5 +/- 6.9 weeks. The mean birth weight was 1373.8 +/- 1196.7 gm and perinatal survival rate was 48.0% (12/25). There was statistically significant difference between urgent cerclage and emergent cerclage based on our finding, The gestational age, birth weight and perinatal survival rate in urgent cerclage were not different from prophylactic cerclage. However, in emergent cerclage, these data were different from the other two cerclages. CONCLUSION: These data suggest that perinatal outcomes after urgent cerclage were comparable to those of prophylactic cerclage. Urgent cerclage could be a valuable alternative to a policy of uniform prophylactic cerclage.

ORAL MICROBES ASSOCIATED WITH TITANIUM IMPLANT AND THEIR ANTIBIOTIC SUSCEPTIBILITY