Fetal survival after umbilical cord prolapse for more than three days. A case report.

BACKGROUND: Umbilical cord prolapse is an uncommon obstetric emergency. CASE: A 28-year-old woman, gravida 1, para 0, presented at 23 2/7 weeks' gestation with vaginal leakage of fluid. She was diagnosed with umbilical cord prolapse. Due to the fetus's extreme prematurity, she was managed expectantly. On hospital day 4, we documented severe variable decelerations. After extensive counseling, the patient and her husband decided to deliver by cesarean section. The infant, a 505-g female, spent 54 days in the neonatal intensive care unit. At the eight-month follow-up examination, she was neurologically intact, with no long-term complications secondary to the prolapsed cord. CONCLUSION: To the authors' knowledge, this case entailed the longest reported interval from diagnosis of umbilical cord prolapse to delivery.

Congenital fiber-type disproportion presenting antenatally with clubfoot and hydramnios.

This is a case of congenital fiber-type disproportion that presented prenatally with bilateral clubfoot, hydramnios, and reduced fetal movements. Although prognosis is generally good for this condition, the neonate presenting at birth may have a more severe form of congenital fiber-type disproportion with a high rate of mortality.

Temporal expression of inducible nitric oxide synthase in mouse and human placenta.

The aim of this study is to investigate the changes in expression and activity of inducible nitric oxide synthase (iNOS) in the developing murine embryo and mouse and human placenta. Using reverse transcription-polymerase chain reaction (RT-PCR), Northern blotting, and in-situ hybridization (ISH) we identified iNOS mRNA in mouse placenta at 9.5, 12, 14, 16, 18 and 20 days post coitum. Northern blot analysis demonstrated that the quantity of murine iNOS transcript was expressed at a stable level between days 12-20 although the level of calcium-independent NOS activity declined with advancing gestation. RT-PCR detected iNOS-specific mRNA in murine embryonic stem cells, but not in embryos at later stages (4-cell or blastocyst). ISH failed to show iNOS-specific mRNA in either murine placenta or the underlying myometrium on day 7, but did so in the trophoblast by day 9.5. Later in gestation, extensive labelling was observed in both spongiotrophoblast and trophoblast giant cells. iNOS mRNA was also detected both in immature human placentae (16-18 weeks) and at term, predominantly in syncytiotrophoblasts and placental artery smooth muscle. In conclusion, iNOS is constitutively expressed in mouse and human placenta at a time and in a location that suggests a role in placentation.

Antenatal sonographic diagnosis of club foot with particular attention to the implications and outcomes of isolated club foot.

OBJECTIVE: There are no studies to date on the implications and outcomes of antenatally detected isolated club foot. The purpose of this study was to perform a contemporary evaluation of club foot diagnosed in the antenatal period. DESIGN: We performed a retrospective analysis of all ultrasound examinations performed in 1989-96 in the Fetal Diagnosis and Treatment Unit of the University of Iowa Hospitals and Clinics (n = 23,863). SUBJECTS AND METHODS: All cases of club foot (n = 35) were evaluated for the presence of other detectable abnormalities and karyotype results if available. Postnatal follow-up was performed until over 1 year of age. RESULTS: We diagnosed unilateral (n = 18) and bilateral (n = 17) club foot from 17.4 to 37.0 weeks. Defects involving other systems were found in 28 of 35 cases. Of the seven cases considered to be isolated antenatally, three were diagnosed with additional malformations in the neonatal period. CONCLUSION: Most cases of antenatally diagnosed club foot were not isolated. Even when they were thought to be isolated on antenatal ultrasound, over half of them were later found to be associated with additional severe abnormalities that were detectable only in the neonatal period.

Risk of preeclampsia in second-trimester triploid pregnancies.

OBJECTIVE: To determine the magnitude of the risk and the predictive clinical characteristics for development of preeclampsia when triploidy is diagnosed in the second trimester. METHODS: A retrospective analysis of databases maintained by the cytogenetics laboratories at the University of Iowa and University of North Carolina was performed to identify all cases of triploidy. We examined the karyotype, maternal serum screening (particularly the hCG level), ultrasound results, and evidence of maternal hypertensive disease. RESULTS: Seventeen cases of triploidy were identified between 1987 and 1996. Preeclampsia or hypertension complicated six of these cases with onset between 15 and 22.5 weeks' gestation. In these six cases, the serum hCG level was extremely high. Serum screening results were available in seven cases in which preeclampsia did not develop, and the hCG levels were under 0.09 multiples of the median in five of the seven cases. In all six cases in which preeclampsia or hypertension developed, there was sonographic evidence of placentomegaly. Sonographic findings in 16 of 17 cases revealed fetal growth restriction, oligohydramnios, fetal anomalies, placentomegaly, or a combination of these. CONCLUSION: In our series of pregnancies complicated by triploidy, the risk of developing preeclampsia or hypertension in the second trimester was 35%. It appears that elevated serum hCG levels and placentomegaly are associated with a higher risk of preeclampsia but low hCG levels are not. This information is important in counseling patients who are hesitant to terminate a pregnancy purely for a fetal abnormality, even if the anomaly is lethal.

Ruptured bacterial intracranial aneurysm in pregnancy. A case report.

BACKGROUND: Rupture of a documented infectious cerebral aneurysm is a rare complication of infectious endocarditis, with a high morbidity and mortality rate. The only previously reported case was associated with maternal and neonatal mortality. No known report exists of a ruptured bacterial intracranial aneurysm complicating an ongoing pregnancy with maternal or fetal survival. CASE: A 38-year-old, white woman, gravida 9, para 4, at 18 weeks' gestation, developed infectious endocarditis with peripheral and cerebral emboli secondary to intravenous drug abuse, causing renal failure and cortical strokes. She required hemodialysis and also suffered a subarachnoid hemorrhage due to rupture of cerebral bacterial aneurysms. A team approach to her care was necessary. At 28 weeks' gestation she delivered by cesarean section for abruptio placentae. Both the mother and neonate recovered. CONCLUSION: Rupture of mycotic aneurysms can be catastrophic and is often managed surgically. The patient described here was severely affected, and though indicated, surgical intervention was not possible. An aggressive team approach provided a good maternal and fetal outcome.

Estrogen inhibits fetal thymocyte development in vitro.

PROBLEM: Transient involution of the maternal thymus in mice is known to occur during pregnancy. We have previously reported that the hormone responsible for this involution is estrogen. Interestingly, although estrogen crosses the placenta, fetal thymus gland enlarges with advancing gestational age. It is not known if fetal thymocytes are resistant to estrogen or if there are other factors that prevent estrogen from exerting an effect on the development of fetal thymocytes. Therefore we studied the effect of estrogen on isolated fetal thymic glands in vitro. METHOD OR STUDY: Pregnant Balb/c mice were sacrificed at 15 days gestation and fetal thymic lobes were obtained from all fetuses. The glands were cultured in vitro using either control medium or medium to which estrogen was added in two concentrations of 0.5 mg/ 100 ml and 1.0 mg/100 ml. After 12 days of organ culture, total thymocyte counts and phenotypic analysis by three color flow cytometry were performed by using monoclonal antibodies to surface markers of T cells subsets. RESULTS: Estrogen treatment caused a marked suppression of the total number of fetal thymocytes. All CD4 and CD8 defined T cell subsets were reduced with a disproportionate loss of CD4+ single positive (SP), CD8+ SP: CD4+CD8+ double positive (DP) cells. The early thymocyte developmental stages, based on CD44 and CD25 expression, revealed the CD4-CD8-CD3- triple negative compartment (TN) to be composed of almost entirely the earliest population (CD44+CD25-) with the remaining maturational stages depleted. CONCLUSIONS: This study demonstrates that fetal thymus removed from the intact fetus is susceptible to the inhibitory effects of estrogen. Since the fetal thymus enlarges with advanced gestational age, it is clear that the intact fetus invokes a regulatory mechanism which neutralizes the anti-lymphopoietic action of estrogen observed in the adult female.

Inhibition of interleukin-10 during pregnancy results in neonatal growth retardation.

PROBLEM: Interleukin 10 is considered to be important in the survival of the fetus in murine pregnancies that are known to be at risk for fetal wastage. The function of IL-10 in a normal pregnancy is not known. METHODS: In this report, we attempted to neutralize Interleukin 10 by administering anti IL-10 monoclonal antibodies (mAb) to pregnant mice that have a low background risk for fetal resorptions. The first group of mice was sacrificed on gestation day 18 to study the fetal effects of anti IL-10 administration. The second group of mice was allowed to deliver to study the effects on the neonatal outcome. RESULTS: Administration of anti IL-10 mAb did not affect the duration of gestation or the fetal outcome. Neonates exposed to anti IL-10 mAb in utero showed signs of transient growth deficiency starting at 4 weeks of age that spontaneously corrected by 6 weeks of age. CONCLUSIONS: Administration of anti IL-10 mAb does not alter the duration of gestation or the fetal outcome in normal murine pregnancies; however, it appears to be associated with transient neonatal growth problems.

Sonographic and maternal serum screening abnormalities in fetuses affected by spinal muscular atrophy.

Fetuses with degenerative neurological disorders or metabolic diseases rarely exhibit sonographic abnormalities. As a result, prenatal diagnosis, when available, requires invasive testing. Prenatal diagnosis of spinal muscular atrophy (SMA) can be made by testing chorionic villi or amniocytes. Indirect genotype analysis by use of single- and multi-locus polymorphic microsatellites of the region 5q11.2-q13.3 is used. We present two cases of SMA that manifested at 11 and 16 weeks' gestation by the presence of abnormal ultrasound findings. Each case also had abnormal maternal serum screening.

Neonatal intracerebellar hemorrhage after forceps delivery. Report of a case without neurologic damage.

BACKGROUND: Neonatal intracerebellar bleeds are very rare and often seen in association with forceps or vaginal breech deliveries. Frequently the neonate requires surgical evacuation of the hemorrhage. These neonates are most often left with significant neurologic sequelae. Medical management has been reported but with poor outcomes. CASE: A primigravida with a twin gestation delivered at 37 weeks. The delivery was facilitated by the use of low forceps for both infants. Twin B was diagnosed with a massive intracerebellar bleed on day 2 of life. She did not undergo surgical drainage due to an improvement in her clinical status. Follow-up examinations were completely normal, and the infant was developing normally at 2.5 years of age. CONCLUSION: Low forceps deliveries can be associated with massive neonatal cerebellar hemorrhage, and these bleeds can be managed successfully without surgical drainage.

Practice patterns during the third stage of labor: the effect of physician age and specialty.

BACKGROUND: Elective manual removal of the placenta and routine uterine exploration following vaginal delivery are controversial procedures. Although advocated in the past, little is known about current attitudes and practices related to these procedures. METHODS: Using a mailed questionnaire, we surveyed all 178 Iowa obstetrician-gynecologists and a random sample of 163 Iowa family physicians to determine their practice patterns related to selected aspects of the third stage of labor. The data were analyzed using odds ratios and multiple logistic regression. RESULTS: The analysis was based on answers from 302 physicians. Physicians in the oldest age quartile were three times more likely than physicians in the youngest age quartile to routinely explore the uterus after a vaginal delivery (P < .01). After controlling for specialty, younger physicians were more likely to believe that manual removal of the placenta is a risk factor for endometritis (adjusted odds ratio [OR] 0.7 for each 10-year increase in age, 95% confidence interval [CI] 0.6 to 1.0). Controlling for age, family physicians were more likely than obstetrician-gynecologists to routinely order prophylactic antibiotics after manually removing the placenta (adjusted OR 2.0, 95% CI 1.1 to 3.7). CONCLUSIONS: Both physician age and specialty were associated with selected practice patterns involving the third stage of labor. Older physicians were less likely to believe that manually removing a placenta increases the risk of postpartum endometritis, and they were more likely to routinely explore the uterus after a vaginal delivery.

Estrogen blocks early T cell development in the thymus.

PROBLEM: Pregnancy and estrogen are known to suppress B lymphopoiesis as well as lead to thymic involution in the mouse. Additionally, estrogen deficiency by oophorectomy reportedly causes a selective increase in the B220+ B cells in the murine bone marrow. The purpose of this study was to determine if estrogens played a regulatory role in T cell development. METHODS: The first experimental group consisted of 5-6-week-old Balb/c mice that received subcutaneous pellets of placebo, estriol, estradiol, or progesterone. The thymus glands were examined 2-4 weeks after treatment. The second group consisted of 6-week-old Balb/c mice who underwent either bilateral oophorectomy or a sham procedure. Two weeks after the surgery, extensive phenotypic characterization of the thymus and spleen cells was performed by flow cytometry using monoclonal antibodies to surface markers of T cell subsets. RESULTS: Estrogen treatment causes a dramatic reduction of thymic size and cellularity. All defined T cell subsets of CD4 and CD8 were reduced, with a disproportionate loss of CD4+CD8+ double positive cells. Examination of the triple negative (CD3-CD4-CD8-) subset revealed a striking loss of TN developmental progression of the early precursor cells. Based on the expression of CD44 (pgp-1) and CD25 (IL-2R alpha) markers, the TN thymic compartment was composed almost entirely of the earliest population (CD44+, CD25-), with the remaining maturational stages (CD44+, CD25+; CD44-, CD25+; CD44-, CD25-) depleted. In contrast, all T cell developmental stages in the thymus were found to be in normal proportions in the oophorectomized mice, with no differences in the splenic T and B cell subsets. CONCLUSIONS: The study demonstrates that estrogen but not progesterone blocks T cell development in the thymus. However, contrary to our expectation, estrogen deprivation by oophorectomy does not enhance T cell development.

Benign fever following vaginal delivery.

BACKGROUND: In patients with fever following vaginal delivery, physicians must differentiate benign self-resolving fevers from fevers with more serious causes, especially endometritis. To help differentiate these clinical entities, we explored the characteristics and risk factors for benign "single-day" postpartum fever. METHODS: We conducted a retrospective cohort study of 2137 vaginal deliveries. Patients were randomly selected from the 25,687 vaginal deliveries that took place between 1979 and 1992 at The University of Iowa Hospitals and Clinics. The data were analyzed using odds ratios and multiple logistic regression. RESULTS: Benign fevers occurred in 3.3% of patients, while endometritis was diagnosed in 1.6%. After controlling for confounding variables, two clinical factors were independently associated with single-day fever: primiparity (odds ratio [OR], 3.4; 95% confidence interval [CI], 2.0 to 5.7) and use of a uterine pressure catheter (OR, 2.4; 95% CI, 1.5 to 3.7). These factors were not associated with endometritis. The first postpartum temperature elevation ( > or = 38.0 degrees C) occurred earlier in patients with single-day fever than in patients with endometritis (4.0 +/- 4.6 hours postpartum vs 30.2 +/- 27.0 hours postpartum, P < .001). The maximum temperature elevation was lower, on average, in patients with single-day fever than in patients with endometritis (38.2 degrees +/- 0.2 degrees C vs 38.9 degrees +/- 0.6 degrees C, P < .001). CONCLUSIONS: Single-day fever was more likely to occur in primiparous women and in women who were monitored with a uterine pressure catheter. Most women with benign single-day fevers had early low-grade fevers, whereas women with endometritis had higher fevers that occurred later in the postpartum period.

Effect of pregnancy on thymic T cell development.

PROBLEM: The thymus gland decreases in size during pregnancy. The significance of this alteration is not known. METHOD: In this report, we examined thymic function by evaluating the development of T lymphocytes in the thymus of pregnant Balb/c mice at 15 and 20 days gestation using multi-color flow cytometry. Comparative analysis was made with non-pregnant mice, post-partum lactating mice, and postpartum non-lactating mice. RESULTS: Progressive reduction of thymic size and cellularity during pregnancy was observed. All of the CD4 and CD8 defined subsets were reduced, with a disproportionate loss of CD4+, CD8+ double positive cells. Examination of the CD4-, CD8- double negative compartment revealed a predominance of TCR alpha, beta+ double negative cells, and a striking loss of precursor cells. The CD3-, CD4-, CD8- triple negative thymic subset was composed almost entirely of the earliest population (CD44+, CD25-), with the remaining maturational stages (CD44+, CD25+; CD44-, CD25+; and CD44-, CD25-) depleted. At 2 weeks postpartum, the subset ratios normalized, and the total cell count showed recovery. CONCLUSION: T cell development is blocked at the precursor level during the mouse pregnancy. These effects are transient, and gradual recovery is observed in the postpartum period.

The association between manual removal of the placenta and postpartum endometritis following vaginal delivery.

OBJECTIVE: To determine whether manual removal of the placenta after vaginal delivery is a risk factor for postpartum endometritis. METHODS: A retrospective cohort study of vaginal deliveries compared 1052 patients who had manual removal of the placenta with 1085 patients whose placentas delivered spontaneously. Subjects were selected randomly from the 25,687 vaginal deliveries at the University of Iowa Hospitals during 1979-1992. The presence of endometritis was determined using information in medical records. The data were analyzed using odds ratios (OR) and multiple logistic regression. RESULTS: After controlling for confounding variables, manual removal of the placenta was associated with postpartum endometritis (adjusted OR 2.9, 95% confidence interval [CI] 1.7-4.9). Other risk factors for endometritis included maternal age less than 17 years (OR 3.3, 95% CI 1.5-7.2), postpartum anemia (OR 2.9, 95% CI 1.9-4.5), and membranes ruptured longer than 24 hours (OR 2.5, 95% CI 1.4-4.3). CONCLUSION: Manual removal of the placenta is a risk factor for postpartum endometritis after vaginal delivery.

Ampicillin/sulbactam versus ampicillin alone for cesarean section prophylaxis: a randomized double-blind trial.

To study the effectiveness of anaerobic coverage in prevention of postpartum endometritis in women undergoing nonelective cesarean sections, we conducted a randomized prospective double-blind study of women undergoing cesarean sections and requiring antibiotic prophylaxis from April 1, 1989, through December 31, 1990. Ninety-four patients were enrolled in the study. Forty-five patients received ampicillin alone and 46 received ampicillin in conjunction with sulbactam. All patients were evaluated prior to surgery and in the postoperative period. Ninety-one patients completed the study and their records were analyzed. Patients were divided into two groups depending on the presence or absence of ruptured membranes. Seventy-five percent of patients had ruptured membranes. Failure of prophylaxis and subsequent endometritis was documented in 8.8% of patients who received ampicillin and sulbactam and 35.3% of patients who received ampicillin alone. This difference was statistically significant (p < 0.02). In conclusion, single-dose ampicillin and sulbactam provides better prophylaxis than single-dose ampicillin in women undergoing cesarean section with rupture of membranes.

Prenatal ultrasound diagnosis of amelia.

Amelia is a very rare form of limb reduction defect. The incidence of isolated amelia with or without other limb reductions is 0.4 per 100,000 births. We report a cluster of three cases diagnosed prenatally. One was isolated tri-amelia and two were isolated tetra-amelia.

Diamond-blackfan anemia in pregnancy.

BACKGROUND: Diamond-Blackfan anemia is a rare form of congenital red-cell aplasia. Approximately 90% of the patients are diagnosed by 1 year of age. This report presents two pregnancies with good outcomes in a patient over a period of 1.5 years. CASE: The patient, a 20-year-old woman, was diagnosed with Diamond-Blackfan anemia at age 3.5 months. Treatments consisted of red blood cell transfusions and oral corticosteroids. She conceived at age 18 years and delivered prematurely at 34 weeks' gestation. Her second pregnancy was diagnosed 4 months after delivery of the first child, and she delivered spontaneously at 38 weeks and 6 days' gestation. She received multiple blood transfusions during both of the pregnancies. The infants were average for gestational age and had normal examination at birth. CONCLUSION: Based on this case and a review of the literature, it appears that pregnancy and birth control pills may contribute to the relapse of anemia in patients diagnosed with Diamond-Blackfan syndrome. This may require an increase in the frequency of blood transfusions. Pregnancies are usually tolerated well and can be managed with supportive therapy.