Persistence of partial molar placenta and severe preeclampsia after selective termination in a twin pregnancy.

BACKGROUND: Triploid molar pregnancies are usually managed by evacuation of the uterine contents. CASE: A 25-year-old woman had a clomiphene citrate-induced twin pregnancy. Ultrasound scan at 13 weeks revealed one anomalous twin. Cytogenetic analysis revealed a karyotype of 69, XXY and a normal other twin. In an attempt to salvage the normal fetus, selective termination was successfully performed at 15 weeks by intracardiac potassium chloride injection. However, the placenta continued to grow and severe preeclampsia developed at 19 weeks, requiring pregnancy termination. CONCLUSION: Selective termination of a triploid twin does not guarantee resolution of molar growth and sequelae of the mole; severe preeclampsia can still develop.

Progesterone and estrogen are potential mediators of gastric slow-wave dysrhythmias in nausea of pregnancy.

Women in pregnancy experience nausea, which correlates with gastric slow-wave rhythm disruption. Mediators of these dysrhythmias were explored. To quantitate slow-wave disruption, eight pregnant women with first-trimester nausea underwent electrogastrography after a 250-kcal meal. Results were compared with nonpregnant women with nausea during a prior pregnancy who received estradiol and/or progesterone to levels of the first trimester of pregnancy. Five pregnant women exhibited dysrhythmias, with increases in combined recording time in tachygastria plus bradygastria, as well as decreases in the percentage of electrogastrography signal power in the normal 3 cycle/min range (cpm), compared with nonpregnant women (P<0.05). Estradiol did not evoke dysrhythmias in nonpregnant women; however, progesterone induced increases in recording time in bradygastria plus tachygastria and increases in bradygastric signal power with corresponding decreases in signal power in the 3-cpm range (P<0.05). With estradiol and progesterone coadministration, an additive effect was observed at 3.3 +/- 0.8 h, with increased recording time in bradygastria alone and in bradygastria plus tachygastria with corresponding increases in bradygastric signal power and decreases in power in the 3-cpm range (P<0.05). In conclusion, women with nausea of pregnancy exhibit slow-wave rhythm disruption. Similar dysrhythmias are evoked in nonpregnant women by progesterone alone or in combination with estradiol in doses that reproduce levels in pregnancy. Thus gastric dysrhythmias in pregnancy may be due to a combination of elevated progesterone and estrogen levels.

Dyspepsia: preliminary experience with upper gastrointestinal fibreoptic endoscopy in Eldoret.

Fibreoptic oesophagogastroduodenoscopy (OGD) was performed on 45 dysplastic patients suspected of having peptic ulcer (PU). Evidence of PU was found in 39.9% and no abnormality was detected in 60%. Epigastric pain alone (62.2%) and with vomiting (15.5%) were the major reasons for suspecting PU. There were no complications arising from the procedure. It is concluded that OGD is a safe procedure which should be made more available and that the pattern of PUD in Eldoret is similar to that in Nairobi.

Pancreatic cancer presenting with resolving pseudocyst during octreotide therapy.

Pancreatic cancer presenting as acute pancreatitis is relatively uncommon. Pancreatic cancer should be included in the differential diagnosis of "idiopathic" acute pancreatitis, particularly in the elderly. The following case report describes a patient in whom pancreatic cancer presented as acute pancreatitis with pseudocyst formation and subsequent resolution with octreotide therapy. Various implications of this case are reviewed.

Angiotensin-converting enzyme inhibitor fetopathy.

Angiotensin-converting enzyme (ACE) inhibitors are widely used for controlling hypertension. Their use in women who are pregnant is not without risk to the fetus. We describe three infants exposed in utero to ACE inhibitors who had adverse outcomes. These cases, combined with other reports in the literature, suggest strongly that these drugs are fetotoxic. ACE inhibitor fetopathy is characterized by fetal hypotension, anuria-oligohydramnios, growth restriction, pulmonary hypoplasia, renal tubular dysplasia, and hypocalvaria. Although the true frequency of adverse fetal effects has yet to be determined, because of the debilitating and lethal nature of the fetal damage when it occurs, it is our recommendation that ACE inhibitors not be used in pregnancy, particularly in the second and third trimesters.

Anti-Yta does not cause hemolytic disease of the newborn.

Anti-Yta has been reported to cause hemolytic disease of the newborn. We present a pregnancy complicated by anti-Yta alloimmunization. Based on reassuring monocyte monolayer assay results, the pregnancy was followed without invasive testing. The infant subsequently had a benign course in the nursery. We conclude that anti-Yta did not cause hemolytic disease of the newborn.

Spontaneous resolution of nonimmune hydrops fetalis secondary to human parvovirus B19 infection.

Many instances of nonimmune hydrops fetalis ascribed to human parvovirus B19 have been reported. The leading proposed pathophysiologic mechanism of hydrops in affected fetuses is viral invasion of red blood cell progenitors, causing a profound reticulocytopenic fetal anemia. Although the natural history of fetal parvovirus infection remains to be elucidated fully, there have been recent reports of funipuncuture and intrauterine blood transfusions to diagnose and manage this problem. We report two pregnancies in which parvovirus-related hydrops fetalis was observed to resolve without intervention, followed by uncomplicated vaginal deliveries of healthy infants. These observations emphasize the need for further investigation before recommending routine fetal blood transfusion in affected cases.

Twin gestation: influence of placentation on fetal growth.

To study fetal growth in twin gestation, morphometric autopsy data of 52 midgestation twin pairs who were stillborn or who died less than or equal to 24 hours after birth were analyzed. Twins were divided into three groups: (1) monozygotic: diamniotic, monochorionic placenta (n = 18); (2) dizygotic: diamniotic, dichorionic placenta, unlike sex (n = 12); (3) like-sex: placenta diamniotic, dichorionic in 63.6%, unknown in 36.4% (n = 22). The monozygotic group had a significantly higher rate of growth discordance, which was defined as a greater than 20% difference in body weight (monozygotic 72.2%, dizygotic 16.7%, like-sex 0%), and polyhydramnios (monozygotic 50%, dizygotic 0%, like-sex 9.1%). Organ weight z scores for body weight and brain weight standards were calculated for the smaller and larger of each twin pair. In the monozygotic group highly significant z scores were obtained for brain weight in the smaller twin (z = 2.71, p = 0.003, body weight standards) and heart weight in the larger twin (body weight standards, z = 3.87, p less than 0.001; brain weight standards, z = 3.64, p less than 0.001). We conclude that monozygotic twins with diamniotic, monochorionic placentation have a high degree of brain-sparing growth restriction in the smaller twin and cardiac hyperplasia in the larger twin, most likely caused by hemodynamic inequalities.

Pharmacokinetics and pharmacodynamics of nifedipine in pregnant sheep.

The calcium channel blocker nifedipine was administered to pregnant sheep by a four-level iv infusion at rates of 1-10 micrograms/kg/min. The maternal and fetal plasma nifedipine concentrations were measured along with maternal and fetal heart rate, blood pressure, pH, and blood gases. The two-compartment maternal pharmacokinetics demonstrated a rapid phase t1/2 of 11 min and a slower phase t 1/2 of 137 min. The drug reached the fetus via a first-order process with a t 1/2 of 22 min. At the highest dose, the maternal systemic vascular resistance dropped 49% in association with a 59% increase in heart rate. The uterine blood flow decreased 29%. Tachycardia was the only significant effect in the fetus. In a subgroup of sheep, chronic dosing with phenobarbital increased maternal nifedipine clearance 3-fold.

Cystic fibrosis, genetics, and DNA technology.

Advances in molecular genetics are leading to changes in practice that have a direct impact on the obstetrician and gynecologist. New techniques of prenatal screening, diagnosis, and potentially therapy are rapidly evolving. Recent developments in cystic fibrosis, preimplantation genetics, fragile X syndrome, neurofibromatosis, muscular dystrophy, and Marfan syndrome are discussed.

Prediction of risk for preterm delivery by ultrasonographic measurement of cervical length.

Risk assessment for preterm delivery remains difficult, particularly among women with no prior history of preterm birth. We hypothesized that accurate assessment of cervical length by endovaginal ultrasonography could predict preterm delivery risk. A total of 178 patients with singleton gestations and without cervical incompetence were studied with transabdominal ultrasonography and endovaginal ultrasonographic cervical length measurement and manual vaginal examination of cervical length. A total of 113 patients who were evaluated by 30 weeks' gestation (excluding four induced preterm deliveries) were analyzed. Preterm delivery risk was compared between women with cervical lengths equal to or greater than the median and those with cervical lengths less than the median. An endovaginal ultrasonographic cervical measurement less than 39 mm was associated with a significantly increased risk of preterm delivery (25.0% versus 6.7%) and detected 76% of preterm births. Manual examination of cervical effacement detected 71% of preterm births, but transabdominal ultrasonographic measurement of cervical length was not preditive. Endovaginal ultrasonographic cervical measurement predicted increased preterm delivery risk regardless of parity or obstetric history. Endovaginal ultrasonography is a promising method for the prediction of risk of preterm birth. Because it has the potential to be an objective measure of cervical length, endovaginal ultrasonography may be superior to manual digital examination for preterm delivery risk assessment.

Percutaneous umbilical blood sampling and umbilical vein transfusions. Rapid serologic differentiation of fetal blood from maternal blood.

Percutaneous umbilical blood samples (PUBS), obtained under ultrasound guidance, are used for prenatal diagnosis and management of hemolytic disease of the newborn (HDN) and other fetal disorders. Rapid testing at the time of sampling is vital to distinguish fetal from maternal blood. Blood typing was performed by slide technique in the treatment room during 38 procedures on 25 patients. Anti-I was used to test 50 presumed PUBS; venous I-positive maternal blood was tested in parallel. Because anti-I cannot detect fetal blood after umbilical vein transfusion (UVT) of I-positive donor blood, ABO and Rh blood typing reagents were used to test 29 samples when maternal and fetal or donor blood groups differed. Monoclonal reagents were used for optimal detection of weak AB antigens in fetal blood. Avid, chemically modified anti-D was used for Rh typing. Blood typing showed 27 (34%) of 79 samples to be maternal blood. Fetal blood was obtained in 8 of 10 cases investigated for fetal disorder and in 16 cases of potential HDN (anti-D, 5; -CD, 5; -cE, 2; -K, 2; -c; -E). The absence of HDN (antigen-negative fetus) was determined in 4 cases. UVT afforded live birth of 9 of 10 infants with HDN and was not indicated in two cases.

Prenatal diagnosis of cystic fibrosis by chorionic villus sampling using 12 polymorphic deoxyribonucleic acid markers.

This report describes the application of a genetic prenatal diagnostic test for cystic fibrosis to a family with a cystic fibrosis-affected child. The test uses 12 deoxyribonucleic acid (DNA) markers that bracket the cystic fibrosis gene on chromosome 7, and chorionic villus tissue as a source of DNA from the fetus at risk for cystic fibrosis. The fetus was predicted by DNA analysis to be unaffected (although a carrier of one cystic fibrosis gene); this diagnosis was confirmed postnatally by the standard sweat electrolyte test. The genetic linkage test is informative in more than 99% of families with cystic fibrosis-affected members and is also useful for determination of carrier status. The test is both more informative and more accurate than one based upon the markers Met and D7S8 (J3.11) alone. The analysis can be done directly from chorionic villus tissue, and therefore can provide a diagnosis as early as nine to 12 weeks after conception.

Comparison of amniotic fluid disaturated phosphatidylcholine and the lecithin-sphingomyelin ratio in the prediction of fetal lung maturity.

Although use of the lecithin-sphingomyelin (L/S) ratio has contributed to a reduction in the frequency of respiratory distress syndrome (RDS), its accuracy in pregnancies complicated by fetomaternal disease has been questioned. Disaturated phosphatidylcholine is the major active component of surfactant and has been advocated as being a more specific indicator of fetal lung maturity. A study of 105 pregnancies in which a L/S ratio and disaturated phosphatidylcholine assay were performed on amniotic fluid was carried out to ascertain if amniotic fluid disaturated phosphatidylcholine is indeed a more accurate predictor of RDS. The results of this investigation reveal no significant difference in the reliability of these two tests in predicting neonatal RDS. Five infants developed RDS with a mature L/S ratio ranging from 2.0 to 3.36, suggesting that the disaturated phosphatidylcholine assay may be a helpful adjunctive test in instances in which the L/S ratio is less than 3.5.