Perinatal outcome in normal pregnant women with incidental thrombocytopenia at delivery.

OBJECTIVE: To investigate the perinatal outcomes of women who suffered from thrombocytopenia at delivery but did not have other diseases during pregnancy. MATERIALS AND METHODS: We considered all singleton deliveries after 24 weeks of gestation at Chang Gung Memorial Hospital, Taipei, Taiwan between 2001 and 2010. Women were excluded from this study if they suffered from any of the following conditions: chronic hypertension, hepatitis, acute fatty liver, liver cirrhosis, nephropathy, overt diabetes mellitus, connective tissue disease, systemic lupus erythematosus, or immune thrombocytopenia. Pregnancies complicated by gestational hypertension, preeclampsia, or fetal anomalies during gestation were also excluded. A total of 18,384 deliveries were included for analysis. Women were divided into three groups according to platelet count at admission. RESULTS: A total of 787 pregnancies (4.3%) were complicated by thrombocytopenia. Thrombocytopenic women had a significantly higher rate of cesarean delivery compared to women who did not have this condition. No other differences were observed among these three groups regarding the rates of adverse pregnancy outcomes. CONCLUSIONS: The results indicate that women who suffered from incidental thrombocytopenia at delivery but did not have other diseases during pregnancy were not at increased risk for adverse pregnancy outcomes.

Risk factors and perinatal outcomes associated with idiopathic small for gestational age Taiwanese newborns.

OBJECTIVE: To determine risk factors and perinatal outcomes associated with small for gestational age (SGA) neonates among healthy pregnant women. METHODS: A retrospective cohort study was conducted of 49 945 women who gave birth at Chang Gung Memorial Hospital, Taipei, Taiwan, after 24weeks of pregnancy. Idiopathic SGA newborns (n=3398) were characterized by a birth weight below the 10th percentile for mean weight corrected for GA and fetal sex. RESULTS: Risk factors for idiopathic SGA newborns included hypercoiling of the umbilical cord (adjusted odds ratio [aOR], 3.3; 95% confidence interval [CI], 1.6-7.0); prior fetal death (aOR, 2.8; 95% CI, 2.0-3.9); primiparity (aOR, 1.5; 95% CI, 1.4-1.7); adolescent pregnancy (aOR, 1.5; 95% CI, 1.2-2.0), low prepregnancy weight (aOR, 1.6; 95% CI, 1.5-1.8), low prepregnancy body mass index (aOR, 1.1; 95% CI, 1.0-1.3); short stature (aOR, 1.3; 95% CI, 1.1-1.4); and entangled umbilical cord (aOR, 1.1; 95% CI, 1.0-1.3). Idiopathic SGA newborns correlated with increased risk of adverse perinatal outcomes, including fetal death, low Apgar scores, oligohydramnios, placental abruption, and admission to the neonatal intensive care unit. CONCLUSION: Some risk factors for idiopathic SGA newborns were modifiable, suggesting potential implications for public health.

Bladder volume determination: two-dimensional versus three-dimensional transvaginal ultrasound.

OBJECTIVE: To compare the results of in vivo measurement of bladder volume using three-dimensional (3D) ultrasound with that obtained from 2D ultrasound. MATERIALS AND METHODS: Forty female inpatients with benign gynecologic diseases had urinary bladder volume determined by ultrasound before surgery. Each patient was initially scanned using the conventional transvaginal 2D ultrasound method, followed by transvaginal 3D ultrasound, and finally underwent sterilized catheterization to obtain the actual bladder volume. The relationships between actual bladder volume and each of the 2D and 3D scan volumes were determined. RESULTS: The patients' bladder volumes varied from 30 mL to 590 mL. The mean value of the error measurement using transvaginal 2D ultrasound estimation was 15.7%, and the correlation coefficient was 0.90. The mean value of the error measurement using transvaginal 3D ultrasound estimation was -8.48%, with a correlation coefficient of 0.97. CONCLUSION: Our data showed that the 3D scan tended to underestimate the actual bladder volume, while the 2D scan tended to overestimate it. Nevertheless, each method would suffice as a reliable noninvasive means of predicting actual bladder volume.

Tumor necrosis factor-alpha converting enzyme in the human placenta throughout gestation.

Ectodomain shedding of epidermal growth factor receptor ligands such as transforming growth factor- alpha (TGF-alpha), heparin-binding epidermal growth factor-like growth factor (HBEGF), and amphiregulin (AREG) is considered to be important during implantation. Tumor necrosis factor-alpha converting enzyme (TACE) has been suggested as the major sheddase for these molecules. The objectives of this study are (1) to characterize the expression of TACE in the human placenta throughout gestation; (2) to determine the association between the expression of TACE with TGF-alpha, HBEGF, and AREG; (3) to ascertain whether TACE mediates TGF-alpha, HBEGF, and AREG shedding; and (4) to examine the effect of hypoxia on the expression of TACE. By analyzing a total of 55 villous samples representing different gestational ages, the authors found that TACE was continuously expressed in the placentas throughout gestation and that the levels of TACE were positively correlated with the levels of TGF-alpha, HBEGF, and AREG. Preadministration of a TACE inhibitor in villous explant cultures or transfection of cytotrophoblastic cells with TACE-specific small interference RNA decreased the shedding of HBEGF and AREG. Moreover, hypoxia (2% O(2)) caused an increase in the levels of TACE mRNA and protein in villous explants and primary cytotrophoblastic cells in vitro. These results indicate that oxygen regulates the expression of TACE and that TACE may be important for placental development during human pregnancy.

Risk factors for placental abruption in an Asian population.

The objective of this study was to identify risk factors for placental abruption in an Asian population. The authors conducted a retrospective review of 37 245 Taiwanese women who delivered between July 1990 and December 2003. Pregnancies complicated by placenta previa, multiple gestation, and fetal anomalies were excluded. Multivariable logistic regression was used to adjust for potentially confounding variables and to identify independent risk factors for placental abruption. Three hundred thirty-two women had placental abruption (9 per 1000 singleton deliveries). Women who smoked during pregnancy (adjusted odds ratio [OR] = 8.4; 95% confidence interval [CI] = 3.0-23.9), had gestational hypertensive diseases (adjusted OR = 4.9; 95% CI = 3.3-7.3), pregnancies complicated by oligohydramnios (adjusted OR = 4.2; 95% CI = 2.7-6.7), polyhydramnios (adjusted OR = 3.3; 95% CI = 1.4-7.7), preterm premature rupture of membranes (adjusted OR = 1.9; 95% CI = 1.1-3.1), entanglement of umbilical cord (adjusted OR = 1.6; 95% CI = 1.2-2.1), were of or more than 35 years of age (adjusted OR = 1.5; 95% CI = 1.1-2.0), and had a low prepregnancy body mass index (adjusted OR = 1.3; 95% CI = 1.0-1.6) were at increased risk for placental abruption. Some risk factors for placental abruption among Taiwanese women are the same as those of other ethnic groups, whereas some of the risk factors are different.

Risk factors for placenta previa in an Asian population.

OBJECTIVE: To identify the risk factors for placenta previa in an Asian population. METHODS: This retrospective cohort study involved Taiwanese women delivered between July 1990 and December 2003 at Chang Gung Memorial Hospital, Taipei, Taiwan. Pregnancies complicated by multiple gestation and fetal anomalies were excluded. RESULTS: There were 457 cases of placenta previa (1.2%) among the 37,702 pregnancies analyzed. Risk factors for placenta previa included a prior preterm birth (OR, 6.6; 95% confidence interval [CI], 4.1-10.6); technology-assisted conception (OR, 4.8; 95% CI, 2.9-7.8); smoking (OR, 3.3; 95% CI, 1.2-9.1) or working (OR, 3.8; 95% CI, 2.8-5.3) during pregnancy; maternal age of, or greater than 35 years (OR, 2.0 to 2.2; 95% CI, 1.3-3.7); and previous induced abortions (OR, 1.3-3.0; 95% CI, 1.1-7.1). CONCLUSION: The risk factors for placenta previa were found to be the same for Asian women as those previously recorded for American and European women, but additional factors were detected.

Risk factors for spontaneous preterm delivery before 34 weeks of gestation among Taiwanese women.

OBJECTIVE: To identify the risk factors for spontaneous preterm delivery before 34 weeks of gestation among Taiwanese women. MATERIALS AND METHODS: This retrospective cohort study involved 36,453 Taiwanese women who delivered between July 1990 and December 2003. Pregnancies complicated by multiple gestation, fetal anomalies, and iatrogenic preterm births due to maternal or fetal indications were excluded. RESULTS: Five hundred and five spontaneous preterm deliveries (1.4%) were identified. Risk factors for early preterm delivery included a prior preterm delivery (odds ratio [OR], 16.5; 95% confidence interval [CI], 11.1-24.6), placental abruption (OR, 13.4; 95% CI, 9.4-19.2), history of fetal demise (OR, 11.8; 95% CI, 7.7-18.0), chorioamnionitis (OR, 10.5; 95% CI, 7.4-14.9), oligohydramnios (OR, 10.1; 95% CI, 6.7-15.3), history of abruption (OR, 7.9; 95% CI, 2.4-26.0), unmarried (OR, 6.2; 95% CI, 2.9-13.2), conception by reproductive technology (OR, 2.7; 95% CI, 1.4-5.5), maternal age less than 20 years (OR, 3.5; 95% CI, 1.8-6.7), maternal age greater than 34 years (OR, 1.6; 95% CI, 1.2-2.1), three or more abortions (OR, 1.6; 95% CI, 1.9-2.3), and premature rupture of membranes (OR, 1.6; 95% CI, 1.3-2.0). CONCLUSION: Some of the risk factors for early preterm delivery among Taiwanese women were the same as those of other ethnic groups, whereas some of the other risk factors were different.

Meigs' syndrome in a young woman with a normal serum CA-125 level.

We report on a 27-year-old woman who presented with an ovarian solid tumor (20 x 15 cm) and massive ascites. A physical examination and chest X-ray revealed a moderate amount of pleural effusion on the right side. Cytologic study of the pleural effusion showed reactive mesothelial cells without evidence of malignancy. Gram's stain was negative. The blood chemistry was within normal limits. The serum CA-125 level was 22 (normal, < 35) U/ml, the alpha-fetoprotein (AFP) level was 8 (normal, < 20) ng/ml, and the carcinoembryonic antigen (CEA) was 0.5 (normal, < 5) ng/ml. An explorative laparotomy revealed approximately 1500 ml of serous ascites and a very large multilobulated left adnexal mass (20 x 15 cm) with no malignant cytology in the ascitic fluid. Postoperatively, the pleural effusion spontaneously resolved, and the microscopic examination revealed a benign fibroma-thecoma, confirming the diagnosis of Meigs' syndrome. The symptoms resolved after removal of this pelvic tumor. This is an unusual case of a young female with Meigs' syndrome and a normal serum CA-125 level.

Perinatal outcomes of polyhydramnios without associated congenital fetal anomalies after the gestational age of 20 weeks.

BACKGROUND: Polyhydramnios carries a high rate of complications during pregnancy and adverse perinatal outcomes. We could find no studies of this condition in a large Asian population. The aim of this investigation was to evaluate the risks of adverse perinatal outcomes in a large study population with polyhydramnios without associated fetal anomalies after the gestational age of 20 weeks in Taiwan. METHODS: We retrospectively reviewed the computerized records of women who had babies without associated fetal anomalies after the gestational age of 20 weeks at Chang Gung Memorial Hospital from July 1990 to December 2001. Possible confounding factors that could affect the occurrence of polyhydramnios were analyzed. We then investigated the relative risks of these events to adverse perinatal outcome by adjusting the variants. RESULTS: Significantly higher incidences of preeclampsia, placental abruption, placenta accreta, past history of fetal death or preterm delivery, multiple pregnancy, bodyweight gain > or = 20kg during pregnancy and primiparity were noted in patients with polyhydramnios than in patients without this condition. The presence of polyhydramnios significantly increased the rate of preterm delivery, low birth weight or very low birth weight, low one- and five-minute Apgar scores, fetal death, large for gestational age babies, meconium-stained amniotic fluid, Cesarean section, fetal distress in labor, NICU transfer and neonatal death. CONCLUSIONS: Polyhydramnios carried a higher incidence of adverse perinatal outcomes, such as low Apgar scores, fetal death, fetal distress in labor, NICU transfer and neonatal death, despite exclusion of congenital anomalies from the study population. Detailed antepartum fetal well-being surveillance, intensive intrapartum monitoring and further attention postpartum are warranted in patients with this condition.

Intrapartum spontaneous uterine rupture following uncomplicated resectoscopic treatment of Asherman's syndrome.

Since Asherman first published his series of intrauterine synechiae in 1948, only a few physicians have described the obstetric complications of patients who conceived following surgical treatment of intrauterine synechiae. We present a woman with a history of resectoscopic resection of intrauterine adhesions with a term pregnancy and spontaneous uterine rupture that occurred during the intrapartum period. At emergent cesarean section, hemoperitoneum of approximately 1500 mL was noted and a 10-cm defect was present in the lateral uterine wall; the edges of the defect were bleeding actively. Because of the potential for a disastrous outcome in the rupture of the pregnant uterus, patients treated for Asherman's syndrome should be identified early and appropriate precautions should be taken in their obstetric management.

The impact of interpregnancy interval and previous preterm birth on the subsequent risk of preterm birth.

OBJECTIVE: To examine the impact of the interpregnancy interval and a previous preterm birth on the subsequent risk of a preterm birth. METHODS: A retrospective analysis was conducted on a group of 4072 women who had at least two consecutive births, excluding multiple gestation, fetal anomalies, cervical incompetence, and stillbirth. Multivariate logistic regression was used to investigate the association between interpregnancy interval, preterm birth of the first child in the pair (index pregnancy), and the risk of a preterm birth of the second child in the pair (outcome pregnancy). RESULTS: Women with interpregnancy intervals of less than 12 months (odds ratio [OR] 1.3; 95% confidence interval [CI] 1.0-1.7) were at increased risks of preterm birth with the outcome pregnancy. Furthermore, there was an increased risk for a subsequent preterm birth in women who had a preterm birth in the index pregnancy (OR 4.2; 95% CI 3.0-6.0). The risk decreased as the interpregnancy interval increased, with a relatively low risk at 18 to 48 months; subsequently, it increased sharply. In contrast, women who had delivered their previous infants at term carried an increased risk of preterm birth with the outcome pregnancy only if the interval was less than 6 months. CONCLUSION: A difference was found in the impact of the interpregnancy interval on the subsequent risk of preterm birth between women with a prior preterm birth and those who previously delivered an infant at term.

Real-time and power Doppler imaging of fetal adrenal hemorrhage.

Adrenal hemorrhages are not uncommon in newborns, but they may occur before birth. The incidence of adrenal hemorrhages based on extensive necropsy has been estimated as about 1.7 per 1000 births. With the increasing use of ultrasonography, prenatal recognition of fetal adrenal hemorrhages has become more common in recent years. We report an echogenic abdominal mass, which was found at 36 weeks of gestation using real-time ultrasound, and was enlarged during the 2-week follow-up period. No trauma history was noted during the pregnancy. Since the mass was close to the kidney, we performed power Doppler imaging to localize the lesion and tried to make a differential diagnosis. The left adrenal mass was posterior to the stomach and was without pulsatile blood flow inside. After birth, sonography confirmed a solid homogenous adrenal mass in the newborn. Seven days after birth, the persistent adrenal echogenic mass without resolution by computerized tomography led to a diagnosis of neuroblastoma. The mass was removed by surgery and adrenal hemorrhage diagnosed. The outcome of the adrenal hemorrhage was excellent. The differential diagnosis in unilateral adrenal mass is difficult from the images of 2-D ultrasound since similar pictures may occur among them. In this case, accurate localization of an adrenal mass is feasible using power Doppler imaging (PDI) before birth by determining its blood supply from the middle suprarenal artery. At the same time, fetal adrenal hemorrhages can be demonstrated as an avascular mass, which is the major difference from adrenal tumors. In conclusion, PDI offered more information to localize the adrenal glands from other lesions by separating the blood supply. In addition, the avascular adrenal mass favors the prenatal diagnosis of adrenal hemorrhage.

Severe ovarian hyperstimulation syndrome coexisting with a bilateral ectopic pregnancy.

Management of severe ovarian hyperstimulation syndrome (OHSS) includes hospitalization for fluid and electrolyte management. Abdominal paracentesis is also used as minimally invasive form of management in selected cases of severe OHSS following ovulation induction. However, if pregnancy ensues, the syndrome persists for a longer period, and the clinical manifestations of severe OHSS could mask the picture of a bleeding gestational sac. It could be easily overlooked unless the possibility of an ectopic pregnancy is kept in mind in cases of severe OHSS exacerbated by early pregnancy with or without a previous ectopic pregnancy history. We report a case of severe OHSS with simultaneous bilateral tubal pregnancy following intrauterine insemination (IUI). A 31-year-old woman with polycystic ovarian disease developed severe OHSS during the therapeutic course of IUI. An emergent exploratory laparotomy was performed 14 days after admission, and the operative findings showed persistent profuse bleeding from the bilateral fimbrial ends with marked enlargement of the ampullary portions. A linear salpingotomy was performed by a longitudinal incision along the area of maximal distension of the dilated fallopian tubes to preserve her fertility. We recommend that in cases of severe OHSS exacerbated by early pregnancy, serial serum beta-hCG and transvaginal ultrasound follow-up may be necessary due to the potential association of severe OHSS in pregnancy with an ectopic pregnancy.

Monopolar thermocoagulation in the management of acardiac twins.

OBJECTIVE: To demonstrate the equipment setup and the application of monopolar thermocoagulation in the management of acardiac twins. METHODS: We described 2 cases of acardiac acephalus twins who developed congestive heart failure and polyhydramnios at 20 weeks of gestation. A monopolar wire electrode was inserted through a 14-gauge trocar under ultrasound guidance. The inter-twin circulation was interrupted and confirmed by color Doppler flow examination. RESULTS: Case 1 was detected at 20 weeks of gestation with progression to early signs of fetal congestive heart failure at 22 weeks. This case had smooth operative procedure and delivered a healthy infant at 32 weeks. Case 2 was referred at 24 weeks of gestation with marked fetal congestive heart failure. Although thermocoagulation cessed the inter-twin perfusion, the fetus died in utero 12 h later with persistent irreversible circulatory compensation. CONCLUSION: Monopolar thermocoagulation was an effective and generally available alternative technique to fetal endoscopic surgery for the interruption of vascular communication between acardiac twins.

Ovarian endometrioma associated with very high serum CA-125 levels.

CA-125 is a 220-kD cell surface glycoprotein present in over 80% of non-mucinous epithelial ovarian carcinomas and it occurs in the serum of healthy males and females at low concentrations (< 35 U/mL). Serum CA-125 concentration may also be moderately elevated in several benign conditions, such as pelvic inflammatory disease, uterine fibroids, pregnancy, spontaneous abortion with chromosomal abnormality, and especially in endometriosis. However, serum CA-125 concentration is seldom > 100 IU/ml in endometriosis. In this paper, we present a patient with unilateral ovarian endometrioma associated with abnormally high serum CA-125 level (> 6000 U/mL) and after excision of the ovarian tumor, the CA-125 levels returned to normal. Our case further emphasizes the association of high levels of CA-125 with benign gynecologic conditions and we discussed the possible explanations for this abnormal elevation of CA-125 levels.

Preliminary normal reference values of nuchal translucency thickness in Taiwanese fetuses at 11-14 weeks of gestation.

BACKGROUND: To investigate normal reference values of nuchal translucency (NT) thickness in normal Taiwanese fetuses between 11 and 14 weeks of gestation. METHODS: A prospective study of ultrasound measurements of fetal NT and crown-rump length (CRL) at 11-14 weeks of gestation was conducted in 724 consecutive Taiwanese fetuses between 1998 and 2001. The relationship between NT and 5-mm intervals of the CRL of the fetus was analyzed. NT thickness was converted into multiple of median (MoM) values for the proper CRL. The estimated risk of trisomy 21 was calculated in combination with maternal age and NT MoM. RESULTS: NT thickness increased with increasing CRL and gestational week in the first trimester. The mean (median) of NT thickness at 11-14 weeks was 1.56 (1.50) mm. Values of NT logMoM showed a normal Gaussian distribution with a mean of -0.0062 and standard deviation of 0.1146. The overall frequency of NT thickness of > 2.5 mm and > 3.0 mm was 1.7% (12/724) and 0.7% (5/724), respectively. There were 18 (2.5%) of 724 normal fetuses with the eseimated risk of trisomy 21, based on maternal age and NT thickness higher than 1:300. CONCLUSIONS: Because of weekly variations and racial differences in NT measurements, normal reference values should be established to convert NT thickness into MoM values for calculating the estimated risk of trisomy 21 in first-trimester NT screening.