Outcome of twin-to-twin transfusion syndrome in monochorionic monoamniotic twin pregnancy: systematic review and meta-analysis.

OBJECTIVES: To explore the outcome of monochorionic monoamniotic (MCMA) twin pregnancies affected by twin-to-twin transfusion syndrome (TTTS). METHODS: MEDLINE and EMBASE databases were searched for studies reporting the outcome of MCMA twin pregnancies complicated by TTTS. The primary outcome was intrauterine death (IUD); secondary outcomes were miscarriage, single IUD, double IUD, neonatal death (NND), perinatal death (PND), survival of at least one twin, survival of both twins and preterm birth (PTB) before 32 weeks' gestation. Outcomes were assessed in MCMA twins affected by TTTS not undergoing intervention and in those treated with amniodrainage, laser therapy or cord occlusion. Subgroup analysis was performed including cases diagnosed before 24 weeks. Random-effects meta-analysis of proportions was used to analyze the data. RESULTS: Fifteen cohort studies, including 888 MCMA twin pregnancies, of which 44 were affected by TTTS, were included in the review. There was no randomized trial comparing the different management options in MCMA twin pregnancies complicated by TTTS. In cases not undergoing intervention, miscarriage occurred in 11.0% of fetuses, while the incidence of IUD, NND and PND was 25.2%, 12.2% and 31.2%, respectively. PTB complicated 50.5% of these pregnancies. In cases treated by laser surgery, the incidence of miscarriage, IUD, NND and PND was 19.6%, 27.4%, 7.4% and 35.9%, respectively, and the incidence of PTB before 32 weeks' gestation was 64.9%. In cases treated with amniodrainage, the incidence of IUD, NND and PND was 31.3%, 13.5% and 45.7% respectively, and PTB complicated 76.2% of these pregnancies. Analysis of cases undergoing cord occlusion was affected by the very small number of included cases. Miscarriage occurred in 19.2%, while there was no case of IUD or NND of the surviving twin. PTB before 32 weeks occurred in 50.0% of these cases. CONCLUSIONS: MCMA twin pregnancies complicated by TTTS are at high risk of perinatal mortality and PTB. Further studies are needed in order to elucidate the optimal type of prenatal treatment in these pregnancies. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

First trimester fetal heart rate as a predictor of newborn sex.

OBJECTIVE: To predict the sex of newborns using first trimester fetal heart rate (FHR). METHODS: This was a retrospective review of medical records and ultrasounds performed between 8 and 13 weeks of gestation. Continuous variables were compared using Student's t-tests while categorical variables were compared using Chi-square test. RESULTS: We found no significant differences between 332 (50.7%) female and 323 (49.3%) male FHRs during the first trimester. The mean FHR for female fetuses was 167.0 ± 9.1 bpm and for male fetuses 167.3 ± 10.1 bpm (p = 0.62). There was no significant difference in crown rump length between female and male fetuses (4.01 ± 1.7 versus 3.98 ± 1.7 cm; p = 0.78) or in gestational age at birth (38.01 ± 2.1 versus 38.08 ± 2.1 weeks; p = 0.67). The males were significantly heavier than females (3305.3 ± 568.3 versus 3127.5 ± 579.8 g; p < 0.0001) but there were no differences in the proportion of small for gestational age (SGA), average for gestational age (AGA) and large for gestational age (LGA) infants. CONCLUSIONS: We found no significant difference between the female and male FHR during the first trimester in contrast to the prevailing lay view of females having a faster FHR. The only statistically significant difference was that males weighed more than female newborns.

Cerebral abscess and thrombophilia in pregnancy. A case report.

BACKGROUND: Cerebral abscess in pregnancy is a rare event, with the etiology not well described. We present such a case in association with genetic thrombophilia. CASE: A 36-year-old primigravida with a prior history of bilateral popliteal vein thrombosis and pulmonary embolism presented in early gestation with right hemiparesis, aphasia, disseminated intravascular coagulation and a space-occupying lesion in the left temporal lobe. Stereotactic biopsy confirmed the presence of an abscess. The patient also had a homozygous methylene tetrahydrofolate reductase mutation (C677T), protein S deficiency and lupus anticoagulant, all of which possibly contributed to the thrombosis, infarct, infection and abscess. She was successfully treated with low-molecular-weight heparin and antibiotics and had a term vaginal delivery. CONCLUSION: Recently genetic thrombophilia was reported in association with various complications of pregnancy, but it has never before been described as occurring with a cerebral abscess.

Pregnancy after avascular necrosis of the femur complicating Gaucher's disease.

A patient with type I Gaucher's disease had avascular necrosis of the right femoral head that resulted in an altered bony pelvis and marked restriction of right hip abduction. Enzyme replacement therapy with alglucerase prevented further deterioration and improved thrombocytopenia. Vaginal delivery was achieved with the patient in the left lateral position with exaggerated flexion at the contralateral hip.

Multiple cardiac rhabdomyomas detected in utero.

Prenatal fetal echocardiography studies detected large multiple cardiac rhabdomyomas and led to the diagnosis of tuberous sclerosis. Despite episodes of bradyarrhythmias and severe lung compression in utero, the neonate did well and was discharged home on day 20 of life. On day 30 of life, the infant expired at home from cardiac arrest secondary to arrhythmia.

Single fetal demise in a twin gestation: umbilical vein thrombosis.

BACKGROUND: Single fetal demise in a twin pregnancy is a rare event, the common causes being twin-twin transfusion syndrome, chromosomal or congenital anomalies and abnormalities of the umbilical cord and placenta. Umbilical vein thrombosis is a very rare cause of single fetal demise in twins. CASE: Three days after a reassuring biophysical profile, a 40-year-old primigravida with twin pregnancy presented at 38 weeks' gestation in early labor when demise of 1 of the twins was recognized. She underwent a cesarean section for arrest of labor, delivering twin A, a stillborn female weighing 2, 360 g and twin B, a liveborn male weighing 2,200 g. Umbilical vein thrombus was noted in twin A. CONCLUSION: Umbilical vein thrombosis is a rare and sudden cause of fetal demise.

Chronic lymphocytic leukemia in pregnancy.

Chronic lymphocytic leukemia, a disease predominantly of elderly men, was incidentally diagnosed in a young pregnant patient. She did not require any chemotherapy and had a normal pregnancy outcome. However, she had repeated episodes of respiratory tract infections and anemia that required multiple antibiotics and transfusions. The placenta showed increased numbers of mature-appearing lymphocytes in the intervillous space, consistent with the diagnosis of chronic lymphocytic leukemia. To our knowledge this is the first reported case of chronic lymphocytic leukemia in pregnancy.

Doppler ultrasound characteristics of fetal nasal flow in pregnancies complicated by diabetes mellitus.

The purpose of our study was to determine the Doppler ultrasound characteristics of fetal breathing-related nasal fluid flow velocity in pregnancies complicated by diabetes mellitus and to examine any changes in the timing parameters of fetal breath cycle relative to maternal blood glucose level. Fetal nasal fluid flow velocity was studied in 67 women at 30-41 weeks of gestation. In 37 cases, the pregnancy was uncomplicated; in 13 cases, the pregnancy was complicated by type I diabetes mellitus; and in 17 cases, the pregnancy was complicated by gestational diabetes. At the examination, subjects with diabetes mellitus were grouped by glucose control (normoglycemic and hyperglycemic) and by gestational age: 30-36 weeks and 37-41 weeks. Maternal hyperglycemia was defined as a plasma glucose value ranging from 140 to 205 mg per 100 ml. A continuous videotape record of the spectral Doppler imaging of fluid flow velocity in the nose was made during each study session. Based on a sample of 25 consecutive fetal breaths, the timing components of breath cycles were determined: time of inspiration (Ti), time of expiration (Te), breath-to-breath interval (Ttotal), and ratio of Ti and Te (Ti/Te). There was a statistically significant difference between the Ttotal (msec) at 30-36 weeks' gestation in the cases of diabetes mellitus with maternal normoglycemia (1,050 +/- 68 SEM) and uncomplicated pregnancy with maternal normal carbohydrate intolerance (1,221 +/- 52). There was a similar difference in the values of Te (552 +/- 37 and 660 +/- 29, respectively) at 30-36 weeks. In cases of maternal hyperglycemia at 30-36 weeks' gestation, the value of Te (689 +/- 84) was significantly higher than in cases of normoglycemia (552 +/- 37). At 37-41 weeks' gestation, only the fetal Ti/Te ratio in normoglycemic diabetic patients was significantly lower than in an uncomplicated pregnancy. No differences were found in the other timing parameters at this gestational age group in cases of diabetes mellitus relative to maternal blood glucose level. No relationship was found between the value of maternal blood glucose and either fetal Ttotal (r2 = 0.003), or Ti/Te ratio (r2 = 0.0001) in cases of diabetes mellitus. Expiratory phase of fetal breath cycle even in well-controlled normoglycemic diabetic women, is significantly shorter than in uncomplicated pregnancies before 37 weeks of gestation. Maternal hyperglycemia in these cases prolonged the duration of expiratory phase of fetal breath cycle and significantly decreased the Ti/Te ratio more than 15% at 30-36 weeks of gestation. It is suggested that blood glucose level is involved in the regulation of fetal respiratory center in pregnancies complicated by diabetes mellitus.

Appearance of neuropeptides and NADPH-diaphorase during development of the enteropancreatic innervation.

Pancreatic ganglia are formed by neural crest-derived precursors, are innervated by enteric neurons, and contain neuropeptides. In addition, the enzyme NADPH-diaphorase is located in a subset of enteric and pancreatic neurons. The expression of neural markers (GAP-43 and NC-1), neurotransmitter-related markers (including neuropeptide Y (NPY), vasoactive intestinal peptide (VIP), gastrin-releasing peptide (GRP), galanin (GAL), dopamine beta hydroxylase (DBH), substance P (SP), calcitonin gene-related peptide (CGRP)), and NADPH-diaphorase was studied in the fetal and neonatal rat gut and pancreas (E12-P28) in situ and in vitro. NC-1, GAP-43 and DBH-immunoreactive cells were found in the primordial stomach on day E12, and in the pancreas on day E13, along with NPY in endocrine cells. Pancreatic NPY-immunoreactive neurons were detected by day E18. CGRP was seen in the foregut at day E12 but not in the pancreas until day E14. Other neuropeptides (SP, GAL, GRP and VIP) all appeared in the foregut earlier than in the pancreas. NADPH-diaphorase activity was first found in situ in foregut neurons on day E13, and in the pancreas on day E14, but seen in explants a day earlier. These observations show that development of neurons occurs earlier in the gut than in the pancreas, and that NADPH-diaphorase activity appears earlier than the immunoreactivities of the neuropeptides.

Pregnancy after cardiac transplantation.

A patient who had undergone cardiac transplantation for familial hypertrophic cardiomyopathy 4 years previously underwent a successful normal spontaneous vaginal delivery. Her immunosuppressive therapy consisted of cyclosporine, prednisone, and azathioprine. She showed some evidence of renal insufficiency and had pregnancy-induced hypertension.

Protein S deficiency in pregnancy: a case report.

Protein S deficiency is uncommon, may cause recurrent thrombosis, and may complicate pregnancy. A patient with protein S deficiency presented with a stillbirth followed by postpartum pulmonary embolism. She then had a successful pregnancy managed by anticoagulation and close fetal monitoring.

An unusual complication in a gravida with factor IX deficiency: case report with review of the literature.

Factor IX deficiency (hemophilia B, Christmas disease) is an X-linked recessive coagulation disorder. It occurs in one out of every 25,000-30,000 male births and requires even rarer genetic circumstances for phenotypic expression in females. We report the occurrence of a large, late-trimester subchorionic hematoma in a gravida with factor IX deficiency and with laboratory evidence of consumptive coagulopathy during treatment. The patient was managed conservatively and had a successful outcome at term. The only four reported cases of antepartum management of factor IX deficiency in the English literature are reviewed.

Subchorionic hematomas and the presence of autoantibodies.

Five cases of subchorionic hematoma detected by ultrasonography in patients with threatened abortion are presented. Three of these subjects had antinuclear antibodies, and the remaining two subjects had anticardiolipin antibodies. We recommend that patients with subchorionic hematomas be tested for autoantibodies regardless of their obstetric history.

Recurrent herpes gestationis with postpartum flare: a case report.

A case of herpes gestationis recurring in each pregnancy, with a postpartum flare-up in the last pregnancy, is described. The diagnosis was confirmed by skin biopsy. The first pregnancy ended in a term stillbirth, but there were favorable outcomes in four subsequent pregnancies. Histopathologic examination of the placentas of the last three pregnancies revealed varying grades of villositis. Symptoms improved with oral corticosteroids.

A comparison of the effect of epidural, general, and no anesthesia on funic acid-base values by stage of labor and type of delivery.

The effect of epidural anesthesia on neonatal acid-base status, before, during, and after labor, was determined by review of funic blood-gas values from 142 women with normal term pregnancies and normal fetal heart rate patterns. Funic acid-base parameters were compared by type of anesthesia when stratified by mode of delivery (vaginal, cesarean section in the active phase of labor, or elective cesarean section). Use of epidural analgesia for vaginal delivery was associated with significantly longer labor, lower umbilical arterial pH, higher arterial PCO2 and arterial bicarbonate values. In women who had cesarean section in the active phase of labor, use of epidural anesthesia was associated with significantly lower arterial and venous PO2 values when compared with women who received general anesthesia. Patients who had elective cesarean section with epidural anesthesia had funic acid-base values similar to women who had general anesthesia. Epidural analgesia-anesthesia offers no clear advantage to the uncompromised term fetus.

Amniotic fluid prolactin levels in rhesus isoimmunized patients.

The concentration of prolactin in the amniotic fluid (AFPRL) was measured in 75 samples obtained in the third trimester of 14 isoimmunized women. There was a uniform decline in prolactin levels with advancing gestation in each pregnancy (r = -0.89 to -0.99). The decline in AFPRL was similar in uncomplicated pregnancies. AFPRL levels were not predictive of umbilical cord hemoglobin or bilirubin levels and amniotic fluid lecithin/sphingomyelin ratio.

Fetal heart rate response to intrauterine saline solution flush.

Response of the fetal heart rate to instillation of normal saline solution 5 ml through an intrauterine pressure catheter was observed on 50 occasions. The test was performed only in those patients in whom an intrauterine pressure catheter had been placed. When the fetal capillary pH was greater than 7.24, accelerations of fetal heart rate by 15 beats/min were observed in 39 of 50 occasions. On the other hand, no fetal heart rate accelerations were observed when the fetal capillary was less than or equal to 7.24.