Sono-endoscopic delineation of the placental vascular equator prior to selective fetoscopic laser ablation in twin-to-twin transfusion syndrome.

OBJECTIVE: To assess the safety and efficacy of a new fetoscopic technique in the management of twin-to-twin transfusion syndrome. STUDY DESIGN: Prospective study of fetoscopic treatment and outcome in 10 pregnancies complicated by severe twin-to-twin transfusion syndrome before 24 weeks' gestation. The sono-endoscopic approach was used to identify the placental vascular equator and photocoagulate any vessels crossing this threshold. RESULTS: The mean gestation at treatment was 20 weeks and 3 days. An average of three to four vessels were ablated during each procedure, with a mean operative time of 24 min (range, 14-31 min). The overall survival rate was 55% (11 of 20) with at least one survivor in 70% (seven of 10) of pregnancies. CONCLUSIONS: Fetoscopic laser ablation is a safe and effective form of treatment in the management of severe twin-to-twin transfusion syndrome. This technique, where vessels crossing the placental vascular equator are identified and photocoagulated fetoscopically, is an alternative to the non-selective and selective methods described previously. This new approach is associated with a shorter operating time, less damage to the normal placental surface vasculature and with survival results that are at least as promising as previously reported techniques.

Neurobrucellosis complicating pregnancy: a case report.

BACKGROUND: Brucellosis in humans is an infectious disease which may occur following contact with infected domestic animals or the ingestion of unpasteurized dairy products. It has rarely been described in pregnancy. The diagnosis, neuropsychiatric manifestations, and management of brucellosis in a 3rd-trimester pregnant woman are discussed. CASE: A 24-year-old Mexican female, G(3)P(2002), at 30 weeks gestation presented with fever, shaking chills, night sweats, a non-productive cough, weakness, nausea, vomiting, anorexia, and vague, dull, upper abdominal pain as well as neuropsychiatric findings. Extensive evaluation revealed serologic and culture evidence of Brucella infection. Her worsening neuropsychiatric condition necessitated preterm delivery with satisfactory neonatal and improved maternal outcomes. CONCLUSION: Bacteriologic infection of pregnant women with neuropsychiatric manifestations should prompt a careful investigation, and brucellosis should be considered if there is a travel history possibly compatible with contact with domestic animals or the ingestion of unpasteurized dairy products.

Survival and disease progression in human immunodeficiency virus-infected women after an index delivery.

OBJECTIVE: Our objective was to provide information on survival and disease progression in human immunodeficiency virus antibody-positive pregnant women undergoing prospective evaluation. STUDY DESIGN: After an index delivery, 103 human immunodeficiency virus antibody-positive pregnant women were identified and underwent follow-up for 3 years. The patients were assessed medically and/or gynecologically when hospitalized for a human immunodeficiency virus-related illness or at each follow-up visit. The life-table method was used to estimate the cumulative probabilities of survival and remaining free of acquired immunodeficiency syndrome. Cox's proportional-hazards analyses were used to identify prognostic factors for survival and progression to acquired immunodeficiency syndrome. RESULTS: The majority of human immunodeficiency virus-infected pregnant women were alive 3 years later. Lymphadenopathy syndrome or herpes genitalis was significantly associated with a subsequent diagnosis of acquired immunodeficiency syndrome. Of the 103 original patients, six had acquired immunodeficiency syndrome at the index delivery and acquired immunodeficiency syndrome developed in 24. Approximately 94% of evaluable patients with development of acquired immunodeficiency syndrome had CD4-lymphocyte counts < 200/mm3. The most common opportunistic infection was Pneumocystis carinii pneumonia. Acquired immunodeficiency syndrome and postpartum zidovudine therapy were independent prognostic factors affecting survival. CONCLUSION: Survival was affected by Centers for Disease Control group status of human immunodeficiency virus infection at the index delivery.

A survey of zidovudine use in pregnant women with human immunodeficiency virus infection.

BACKGROUND AND METHODS: The expanding indications for zidovudine treatment make it important to elucidate the safety and toxicity of this drug for pregnant women and their fetuses. We asked pediatricians and obstetricians at the AIDS (acquired immunodeficiency syndrome) Clinical Trials Units to report information about pregnant women infected with the human immunodeficiency virus (HIV) who were continuing their pregnancies and had received, or were receiving, zidovudine during gestation. RESULTS: Reports of 43 women were received from 17 institutions. Doses of zidovudine ranged from 300 to 1200 mg per day, and 24 women took the drug for at least two trimesters. There were two reported instances of maternal toxicity (one gastrointestinal and one hematologic). No teratogenic abnormalities occurred in the 12 infants with first-trimester exposure to zidovudine. All the infants, including two sets of twins, were born alive. The 38 singleton infants born at term for whom birth weights were reported had a mean birth weight of 3287 +/- 670 g; two cases of intrauterine growth retardation were reported among the infants delivered at term. Hemoglobin values, which were available for 31 newborns, ranged from 7.0 to 12.4 mmol per liter (11.2 to 20 g per deciliter); 3 of the 7 newborns with hemoglobin values of less than 8.4 mmol per liter (13.5 g per deciliter) were born prematurely. CONCLUSIONS: Zidovudine was well tolerated by the pregnant women and was apparently not associated with malformations in the newborns, premature birth, or fetal distress. No pattern of hematologic toxicity was observed in the newborns, but the anemia and growth retardation seen in a minority of the infants could, in part, have resulted from their mothers' treatment with zidovudine.

Acoustic stimulation-induced fetal response compared to traditional nonstress testing.

Eighty-eight nonstress tests (NSTs) were obtained on gravid women between 27 and 44 weeks' gestation to compare the results of a three-second acoustic stimulus with a traditional NST. Length of testing time was significantly decreased with the use of acoustic stimulation. Consequently, nursing time and equipment use were also considerably lessened per test. Previous studies indicated that the predictive value of the acoustic stimulation test is comparable or better than the traditional NST.

The Goldston syndrome: report of a case.

We present a case of the Goldston syndrome--that is, cystic renal dysplasia and the Dandy-Walker malformation. The condition was diagnosed by ultrasound in a 635 g fetus in the seventeenth week of gestation. Ultrasound studies showed the fetal head to be somewhat enlarged with slight dilatation of the lateral ventricles and marked dilatation of the fourth ventricle. The kidneys were symmetrically enlarged and multicystic. Autopsy revealed evidence of the oligohydramnios syndrome. The kidneys were typical of the Goldston syndrome as were the microscopic lesions in the liver. To our knowledge this is the first reported case in which this diagnosis was made during intrauterine life.

Human immunodeficiency virus infection in women. I. The effects of human immunodeficiency virus on pregnancy.

The clinical courses and initial neonatal outcomes of 50 patients with human immunodeficiency virus infection were followed on antepartum, intrapartum, and/or postpartum bases, between July 18, 1986, and December 27, 1987, at the University of Miami School of Medicine/Jackson Memorial Medical Center. The mean age at the time of the most recent delivery was 27 years. Cases attributable to the single risk factor of heterosexual transmission acounted for 76% of the cumulative number. Twenty-eight, or 56%, of the total sample were of Haitian ancestry. The patients in this study group did experience several complications of pregnancy. Interestingly, more than one third of the pregnancy courses (34.6%) were complicated by preterm labor. Only 15.4% of the patients had premature rupture of membranes. A higher rate of infection of the genitourinary tract and an increased incidence of sexually transmitted diseases in women known to be infected with human immunodeficiency virus are suggested. Less clear is the contribution of genitourinary tract infections and sexually transmitted diseases to the risk of acquired immunodeficiency syndrome or of perinatal human immunodeficiency virus transmission. Although a total of 10 patients in the study group were known to have children infected with human immunodeficiency virus, only longitudinal studies of the children of the mothers in this group will shed light on the number of children who ultimately become infected with human immunodeficiency virus. Similarly, although the majority of patients in this report remained asymptomatic during the course of their pregnancies, a matched, controlled study is necessary to confirm that pregnancy does not accelerate the progression of human immunodeficiency virus infection.