Candida chorioamnionitis associated with late stillbirth: A case report.

Vulvovaginal candidiasis during pregnancy is common, but serious complications, including chorioamnionitis, are infrequent. A 41-year-old woman presented at 37 weeks of gestation with reduced fetal movements, and fetal death in utero was subsequently confirmed on ultrasound. Histopathology of the cord and placenta revealed Candida infection and microabscesses on the umbilical cord. Overall, these features are suggestive of ascending infection, consistent with Candida as the causative organism. To the best of our knowledge, this is the first reported case of late stillbirth due to Candida chorioamnionitis. More research is needed to determine the mechanism whereby Candida becomes pathogenic in pregnancy. There is also no clear consensus on how to manage such patients in a subsequent pregnancy.

Identification of essential steps in laser procedure for twin-twin transfusion syndrome using the Delphi methodology: SILICONE study.

OBJECTIVE: To determine, by expert consensus, the essential substeps of fetoscopic laser surgery (FLS) for twin-twin transfusion syndrome (TTTS) that could be used to create an authority-based curriculum for training in this procedure among fetal medicine specialists. METHODS: A Delphi survey was conducted among an international panel of experts (n = 98) in FLS. Experts rated the substeps of FLS on a five-point Likert-type scale to indicate whether they considered them to be essential, and were able to comment on each substep, using a dedicated online platform accessed by the invited tertiary care facilities that specialize in fetal therapy. Responses were returned to the panel until consensus was reached (Cronbach's α ≥ 0.80). All substeps that were rated ≥ 4 by 80% of the experts were included in the evaluation instrument. RESULTS: After the first iteration of the Delphi procedure, a response rate of 74% (73/98) was reached, and in the second and third iterations response rates of 90% (66/73) and 81% (59/73) were reached, respectively. Among a total of 81 substeps rated in the first round, 21 substeps had to be re-rated in the second round. Finally, from the initial list of substeps, 55 were agreed by experts to be essential. In the third round, the 18 categorized substeps were ranked in order of importance, with 'coagulation of all anastomoses that cross the equator' and 'determination of fetoscope insertion site' as the most important. CONCLUSIONS: A total of 55 substeps of FLS for TTTS were defined by a panel of experts to be essential in the procedure. This list is the first authority-based evidence to be used in the development of a final training model for future fetal surgeons.

Immediate outcome of twin-twin transfusion syndrome following selective laser photocoagulation of communicating vessels at the NSW Fetal Therapy Centre.

OBJECTIVE: To audit the outcome for laser photocoagulation for twin-twin transfusion syndrome (TTTS) as managed by the New South Wales Fetal Therapy Centre (NSW FTC). METHODS: A retrospective cohort study. Outcome data were reviewed for referrals between June 2003 and June 2008.The outcome measures included the severity of TTTS at presentation, delivery details (gestational age at delivery, birth weight and Apgar score at 5 min) and perinatal outcome (spontaneous miscarriage, premature rupture of membranes, intrauterine death, placental abruption and neonatal death). RESULTS: Seventy-nine patients were treated with laser therapy for stage I-IV TTTS (median stage III). Median gestational age at treatment was 20 weeks (range 16-25). Median gestational age at delivery was 32 weeks (range 24-40). Survival of at least one baby in this study was 90.7% (88.9% for anterior and 92.1% for posterior placenta), and of both babies was 60.0%. Median birth weight was 1788 g (range 490-3695). Median Apgar score was nine at 5 min. Three women required repeat laser treatment for persistent TTTS. CONCLUSIONS: Selective laser photocoagulation of communicating vessels remains the treatment of choice for TTTS. Referrals to the NSW FTC have increased from five cases in the last half of 2003, to 18 cases in the first half of 2008. Local outcome figures at least equal any in the published international literature and support a continued policy of centralised care in Australia. A two-year follow-up study on neonatal outcome for survivors is underway.

Congenital lobar emphysema--the disappearing chest mass: antenatal ultrasound appearance.

Prenatal diagnosis of congenital lobar emphysema is rarely reported in the literature. This case presents a fetus with an echogenic lung diagnosed at 18 weeks' gestation, that resolved completely during the pregnancy. This case is unique in that sonographic increased echogenicity was first noted at 18 weeks' gestation and had disappeared by 29 weeks' gestation. The diagnosis was made in the postnatal period as a result of follow up of the prenatal findings. This case reinforces the importance of continuing postnatal investigations of prenatal sonographic abnormalities even when they appear to have disappeared. A discussion of the causes of congenital lobar emphysema is presented.

Partial mole, triploidy and proteinuric hypertension: two case reports.

We present two cases of proteinuric hypertension in the early second trimester of pregnancy, associated with partial mole and triploidy karyotyping. This demonstrates the complementary nature of ultrasound in the diagnosis and management of this rare association.

Splenic infarction in pregnancy.

We present a case of splenic infarction in pregnancy, secondary to acute bacterial endocarditis. Left upper quadrant pain in pregnancy can be due to a variety of causes and in the septic or unwell patient, splenic infarct should be considered in the differential diagnosis. The diagnosis of splenic infarct should be considered especially in those at increased risk of bacterial endocarditis. Acute bacterial endocarditis can occur even in patients without any risk factors. Bacterial endocarditis is rare in pregnancy and splenic infarction is even rarer. However when it occurs, rapid diagnosis and management are necessary to minimize embolic phenomena. With the increasing use of intravenous drugs and with increasing numbers of Pacific Islanders in our pregnant population, it is important to be alert to the risk of bacterial endocarditis and to avoid serious sequelae. Patient education to the importance of medical follow-up in order to prevent such a life-threatening condition, and to avoid more complicated acute treatment, is imperative.

Observational study of effect of intrauterine transfusions on outcome of fetal hydrops after parvovirus B19 infection.

The role of intrauterine transfusion for fetal hydrops arising from maternal paravirus B19 infection is unclear. 66 cases of fetal hydrops arising from B19 infection were reported in England and Wales between June, 1992, and September, 1994. In 29 cases the fetus was dead at the time of the first abnormal ultrasound or a therapeutic abortion as performed; 12 of the 38 alive at the first abnormal scan received intrauterine transfusions and 3 of the 12 died. 26 did not receive intrauterine transfusions and 13 died. After adjustment for the severity of the hydrops as assessed by the ultrasound and for gestational age, the odds of death among those who received an intrauterine transfusion was significantly less than among those who did not (odds ratio 0.14, 95% CI 0.02-0.96). These findings suggest that intrauterine transfusion will benefit some fetuses with hydrops arising from parvovirus B19 infection.

Fetal behaviour and the sudden infant death syndrome (SIDS).

To examine whether differences in sleep maturation could be identified before birth, behavioural studies were carried out in 28 fetuses. Studies were possible in all 28 fetuses at 28 weeks, but only in 26 fetuses at 36 weeks (two fetuses delivered before 36 weeks). The risk of sudden infant death syndrome (SIDS) was determined using the Oxford SIDS scoring system. The fetuses at greater risk of SIDS had coincidence of behavioural characteristics for a significantly lower percentage of the time than those at low risk. This difference reached significance (p < or = 0.05) only at 36 weeks.

Predictive value of pleural effusions in fetal hydrops.

Twenty-eight cases of fetal hydrops are reported. A diverse aetiology was found. Fetal therapy was undertaken in 12 (42.9%). The overall survival rate was 36.8% (excluding elective terminations). However, when normal fetuses presenting from 20 weeks were considered, the survival rate was 64%. The results were combined with those of two other studies (making a total of 182 cases with fetal hydrops) to ascertain the value of pleural effusions in predicting outcome in such cases. In the 143 cases that did not end in a therapeutic termination of pregnancy, fetal pleural effusions predicted death (fetal or neonatal) with a sensitivity of 67%, a specificity of 53%, a positive predictive power of 68%, a negative predictive power of 52% and an overall accuracy of 62%.

Hydrops fetalis caused by a blood group antibody usually undetected in routine screening.

A case of isoimmunisation in pregnancy caused by antibodies to the Kpa red blood cell antigen is described. The preceding pregnancy had resulted in fetal hydrops for which no cause was found as the antibody screening cells used to investigate the fetal hydrops were Kpa negative. This case emphasises the importance of serological screening at a reference laboratory for low frequency red cell antigens before a diagnosis of non-immune hydrops is made.

Gastro-intestinal crises during pregnancy.

In general pregnancy is not associated with an increase in the incidence of gastro-intestinal (GI) conditions, but it is associated with an increase in the severity of these conditions. This is largely due to a delay in making the diagnosis. Delay is caused by a combination of factors. These include mimicry of symptoms and signs with pregnancy-related conditions, a change in the usual clinical presentation, reluctance to use radiological diagnostic aids and a higher threshold for performing invasive investigative procedures. However before resorting to invasive investigations, it is imperative that appropriate non-invasive investigations are performed and evaluated first. This is especially relevant to liver conditions in pregnancy which can present with abdominal pain. Optimal management of GI conditions in pregnancy requires both surgeons and obstetricians to be aware of the problems of diagnosis, communicate promptly and investigate without delay in order to make a diagnosis and avert a GI crisis. This article discusses the clinical presentation, diagnosis and management of the common GI conditions occurring in pregnancy.

Complex mosaicism associated with trisomy 9.

Fetal karyotypes can be routinely obtained by chorionic villus biopsy, amniocentesis, or fetal blood sampling. Interpretation of results and subsequent counselling can be complicated by pseudomosaicism or mosaicism confined to the placenta or other tissues. We illustrate this by reporting a case of an abnormal fetus with a total of three karyotypically different cell lines (46,XX; 47,XX, +9; and 47,XX, +del(9) (q11) in different tissues (placenta, lung, gonad, and skin).