Placenta accreta and methotrexate therapy: three case reports.

Placenta accreta is a complication that is rising in incidence. The reported experience of methotrexate treatment in the conservative management of placenta accreta is scant. Three cases of placenta accreta managed with methotrexate are presented. Case 1: A woman had an antenatal diagnosis of placenta percreta. A successful manual placental removal occurred on post-cesarean day 16. Case 2: A woman had retention of a placenta accreta after a term vaginal delivery. Successful dilation and curettage were performed on postpartum day 37. Case 3: A woman had an antenatal diagnosis of placenta previa-percreta with bladder invasion. A simple hysterectomy was performed on post-cesarean day 46. Conservative management and methotrexate treatment resulted in uterine preservation in two of our three patients; however, this treatment did not prevent significant delayed hemorrhage. In view of the rapid resolution of vascular invasion of the bladder, methotrexate may have an important role in the management of placenta percreta with bladder invasion. The utility of methotrexate treatment with the conservative management of placenta accreta requires further evaluation.

Preterm delivery in mice with renal abscess.

OBJECTIVE: Our purpose was to develop a mouse model of renal abscess to study the effect of extrauterine infection on preterm delivery. METHODS: Escherichia coli or sterile medium was injected into the left kidney of 70 pregnant mice that had completed approximately 75% of gestation. Preterm delivery rates were recorded for various inocula. Kidney specimens were obtained and examined grossly and histologically for abscess formation. RESULTS: Thirty-one of 51 animals (60.8%) infected with 1 x 10(5)-9 x 10(6) bacteria and none of 19 uninfected animals delivered prematurely (P < .001). Renal abscess was induced in 100% of mice receiving bacterial inoculation but in none receiving sterile medium. CONCLUSION: Kidney injection provides a reliable method for inducing renal abscess in pregnant mice. Renal abscess induces preterm delivery at a stable rate across a wide range of bacterial inocula. This model of extrauterine infection may be particularly useful in investigations of infection-induced preterm delivery.

Fetal death after normal biophysical profile score: An eighteen-year experience.

OBJECTIVE: It was our goal to determine the false-negative rate of the biophysical profile, characterize an 18-year variation in the false-negative rate, examine the relationship between the last normal biophysical profile score and death, and compare the false-negative rate of 2 disparate populations. STUDY DESIGN: Biophysical profile scores of 86,955 patients at 2 medical centers were collected and recorded prospectively. All perinatal deaths occurring within 1 week of a normal score were similarly recorded. The annual false-negative rate, the cumulative false-negative rate, and the ratio of false-negative results in cases of subsequent fetal death to the perinatal mortality rate were calculated. RESULTS: There were 65 fetal deaths among 86,955 fetuses. Over an 18-year study period at one institution, the false-negative rate varied but not significantly. The cumulative false-negative rate was 0.708 per 1000 at one medical center studied and 2.289 per 1000 at the other center. The average interval between last normal score and fetal death was 3.62 days and did not vary significantly between the medical centers. CONCLUSIONS: False-negative results in cases of subsequent fetal death reflect events that are subsequent to the last normal test result. Fetomaternal hemorrhage was the single most identifiable fetal cause of false-negative results in cases of subsequent fetal death. The ratio of the false-negative rate in cases of subsequent fetal death to the perinatal mortality rate should be used as a more objective approach to reporting this value, because the false-negative rate likely reflects the underlying perinatal mortality.

Inflammatory cytokines in a murine model of infection-induced preterm labor: cause or effect?

OBJECTIVE: To characterize the expression of inflammatory cytokines in a murine model of preterm delivery induced by heat-killed bacteria. METHODS: The right uterine horns of female CD-1 mice on day 14.5 of 19-20 days of gestation were inoculated with either sterile media or killed Escherichia coli bacteria (10(5)-10(10) organisms per mouse). The incidence of preterm delivery was recorded. The concentrations of cytokines (interleukin [IL-] 1 alpha, IL-1 beta, IL-1 receptor antagonist [IL-1ra], IL-6, and tumor necrosis factor alpha [TNF alpha]) within maternal and fetal tissue homogenates were determined by enzyme-linked immunosorbent assay at various times after inoculation. RESULTS: Killed E. coli induced preterm delivery in a dose-dependent fashion. Inoculation with 10(10) bacteria (sufficient to cause delivery in all mice) produced increases in IL-1 alpha, IL-1 beta, IL-6, and TNF alpha within uteri and fetal membranes, but not within placentas, fetal bodies, and maternal serum. Maximum mean uterine levels of IL-1 and IL-6 exceeded those of fetal tissues (membranes, placentas, and fetal bodies) by greater than 15-fold. Maximal uterine IL-1 and TNF alpha levels following inoculation with 10(10) bacteria exceeded those that followed inoculation with 10(7) bacteria (below the threshold for delivery) by 2.5- to 5-fold. The anti-inflammatory cytokine IL-1ra was expressed in higher concentrations in fetal than in maternal tissues and was unaltered by the bacterial inoculum. CONCLUSIONS: E. coli induce labor in mice even in the absence of bacterial viability. Although IL-1 and TNF alpha were upregulated by bacterial inocula causing delivery, peak levels were only 2.5- to 5-fold higher than those that occurred with inocula below the threshold for delivery (1000-fold fewer bacteria). Whether IL-1 and TNF alpha mediate labor during in vivo infection, or whether the upregulation of these cytokines merely represents an epiphenomenon accompanying infection, remains unknown.

A murine model of renal abscess formation.

We developed a murine model of kidney abscess by direct renal injection of either Escherichia coli (1 x 10(6) to 7 x 10(6) organisms) or sterile medium. Bacterial infection produced renal abscesses, bacteremia, and late-onset leukocytosis in all animals. Controls were unaffected. This model may be useful for the study of various sequelae of kidney infection.

Atraumatic fetal cervical spinal cord injury and cruciate paralysis.

BACKGROUND: Congenital cervical spinal cord injury usually is attributed to intrapartum mechanical trauma. CASE: A fetal cervical spinal cord hemorrhage presented as congenital isolated upper extremity ("cruciate") paralysis and muscle atrophy after an atraumatic delivery. Timely neonatal diagnosis and surgery resulted in complete recovery. CONCLUSION: Paralysis may result from atraumatic spinal cord injuries occurring in the antepartum period.