Prenatal diagnosis of congenital cytomegalovirus infection in 115 cases: a 5 years' single center experience.

OBJECTIVE: The objective of this study is to investigate the diagnostic value of invasive prenatal diagnosis (PD) of congenital cytomegalovirus (CMV) infection from amniotic fluid (AF) and fetal blood (FB). METHODS: A retrospective study was conducted on 115 pregnancies with CMV primary infection. A total of 111 AF and 106 FB samples were investigated for various virological and non-virological markers. Detailed ultrasound examinations were performed at time of PD. RESULTS: Overall sensitivity of CMV PCR in FB (75.6%; 95%CI 60-87) and AF (72.7%; 95%CI 57-85) was comparable. In women with amniocentesis >8 weeks between seroconversion and PD, we did not observe significant differences between amniocentesis performed ≥17 + 0 (sensitivity 90.9%; 95%CI 71-99) and ≥20 + 0 gestational weeks (sensitivity 90.0%; 95%CI 68-99). Virological markers in FB were higher in symptomatic compared with asymptomatic fetuses (p < 0.05). No significant differences were observed for non-virological markers. However, platelet counts <120 × 10e9/L and beta-2 microglobulin values >14 mg/L were more frequently found in fetuses with severe ultrasound abnormalities compared with fetuses with no or mild abnormalities (p < 0.001). CONCLUSION: Optimal timing of amniocentesis in women with primary infection in early gestation should be reevaluated in a prospective study. Analysis of FB markers may be beneficial in the individual management of pregnant women with confirmed congenital CMV infection. © 2017 John Wiley & Sons, Ltd.

Successful treatment of an infant with CDA type II by intrauterine transfusions and postnatal stem cell transplantation.

Congenital dyserythropoietic anemias are rare hematological disorders leading to ineffective erythropoiesis with chronic anemia, complicated by iron overload. Here we present a remarkable clinical course of an infant with CDA type II who first presented as a severe fetal hydrops, requiring serial intrauterine red cell transfusions. While postnatal transfusion dependency persisted, the patient was successfully transplanted with a myeloablative conditioning regimen and peripheral blood stem cells of a matched donor. We believe that allogeneic HSCT is a reasonable therapeutic approach for patients with very severe CDA, even if only a matched unrelated donor is available.

Cytology at the time of cervical colposcopy.

OBJECTIVE: The efforts of the authors are to evaluate the role of performing a Papanicolaou (Pap) smear at the time of colposcopy. MATERIALS AND METHODS: This retrospective chart review included patients from 2004 to 2009 who underwent cold knife cone (CKC) biopsy or loop electrosurgical excision procedure (LEEP) for cervical intraepithelial neoplasia types 2 and 3 (CIN 2 and 3) or patients with discrepancy between Pap and colposcopic results. All patients presented to the gynecology clinics in a tertiary care hospital. Results were compared which included: the abnormal Pap smear which led to referral for colposcopy, the Pap smear performed at the time of colposcopy, the colposcopic biopsy, and the excisional biopsy. Interpretation of results was calculated with Cohen's K Statistics. RESULTS: One hundred forty-seven patients qualified for the study. One hundred five patients had excisional biopsy proven high-grade squamous intraepithelial lesion (HSIL). Eighty-two of these high-grade excisional pathology results were preceded by high-grade Pap cytology at the time of colposcopy; however 23 Pap cytology results indicated either low-grade squamous intraepithelial lesion (LSIL) or negative (20 and 3 respectively), but were followed by an excisional procedure revealing high-grade pathology. Eighty-one colposcopic biopsies confirmed high-grade excisional biopsy pathology. However, 24 colposcopic biopsies were low-grade or negative (13 and 11 respectively), but followed by a high-grade excisional biopsy. CONCLUSION: The addition of a Pap smear at the time of colposcopy has the potential role of recognizing high-grade cervical dysplasia.

Continuous oral or intramuscular medroxyprogesterone acetate versus the levonorgestrel releasing intrauterine system in the treatment of perimenopausal menorrhagia: a randomized, prospective, controlled clinical trial in female smokers.

OBJECTIVE: To compare the efficacy of three progestin regimens in perimenopausal menorrhagia. DESIGN: One hundred thirty-two women with menorrhagia were included in this prospective, randomized, comparative trial. Women were randomized to three groups of 44 in each, either to get a single shot of depot medroxyprogesterone acetate, intramuscularly (Group 1), or medroxyprogesterone acetate in a daily dose of 5 mg orally (Group 2), or the levonorgestrel releasing intrauterine system (LNG-IUS) (Group 3). The Mann-Whitney U-test was applied to compare independent groups. RESULTS: Pictorial blood loss assessment chart (PBAC) score, the duration of bleeding and mean hemoglobin level were improved in all groups. Comparing the groups we noted that for the PBAC, there was no statistically significant difference between groups 1 and 2, while group 3 was superior to both groups 1 and 2 (p < 0.05 and p < 0.05, respectively). Mean duration of menstruation showed no differences among the groups. Hemoglobin levels were no statistically significant differences between groups 1 and 2, while group 3 was superior to both groups 1 and 2 (p < 0.05 and p < 0.05, respectively). CONCLUSION: The efficacies of oral and intramuscular medroxyprogesterone acetate in the treatment of menorrhagia were comparable each other, however, the efficacy of LNG-IUS was superior to both.

Value of tissue harmonic imaging (THI) and contrast harmonic imaging (CHI) in detection and characterisation of breast tumours.

The purpose of this study was to investigate the extent to which tissue harmonic imaging (THI), speckle reduction imaging (SRI), spatial compounding (SC) and contrast can improve detection and differentiation of breast tumours. We examined 38 patients (14 benign, 24 malignant tumours) with different combinations of THI, SRI and SC. The effect on delineation, margin, tissue differentiation and posttumoral phenomena was evaluated with a three-point score. Additionally, 1oo not palpable tumours (diameters: 4-15 mm) were examined by contrast harmonic imaging (CHI) with power Doppler. After bolus injection (0.5 ml Optison), vascularisation and enhancement were observed for 20 min. The best combination for detection of margin, infiltration, echo pattern and posterior lesion boundary was the combination of SRI level 2 with SC low. THI was helpful for lesions OF more than 1 cm depth. In native Power Doppler, vessels were found in 54 of 100 lesions. Within 5 min after contrast medium (CM) injection, marginal and penetrating vessels increased in benign and malignant tumours and central vessels mostly in carcinomas (p<0.05). A diffuse CM accumulation was observed up to 20 min after injection in malignant tumours only (p<0.05). THI, SRI and SC improved delineation and tissue differentiation. Second-generation contrast agent allowed detection of tumour vascularisation with prolonged enhancement.

Neonatal nucleated red blood cell counts: relationship to abnormal fetoplacental circulation detected by Doppler studies.

Increased neonatal nucleated red blood cell counts are thought to be related to intrauterine hypoxemia. We sought to determine the effect of increasing circulatory impairment in fetuses on the neonatal nucleated red blood cell count. One hundred thirty-four singleton pregnancies were included in the study and were allocated to 4 study groups according to Doppler findings. The systolic-to-diastolic ratios of the umbilical artery, fetal aorta, middle cerebral artery, and uterine arteries were recorded. Fetuses were assigned to the following groups on the basis of the last Doppler examination before delivery: group 1, normal systolic-to-diastolic ratios in the examined vessels; group 2, a systolic-to-diastolic ratio greater than 2 SD above the mean for gestational age in the umbilical artery or fetal aorta and no abnormal Doppler findings in the uterine arteries; group 3, systolic-to-diastolic ratios greater than 2 SD above the mean for gestational age in all examined vessels; and group 4, absence of end-diastolic velocity in the umbilical artery or fetal aorta and systolic-to-diastolic ratios greater than 2 SD above the mean for gestational age in the uterine arteries. A blood sample from the umbilical artery was obtained within 1 minute after birth, and nucleated red blood cells per 100 white blood cells were counted by light microscopy. Nucleated red blood cell counts were higher in fetuses in group 4 (median, 72.0; range, 9-720; P < .001) and group 3 (median, 38.4; range, 7-201; P < .001) than in fetuses in group 1 (median, 5.1; range, 0-20). Neonates in group 4 had significantly lower birth weights (P < .001), lower arterial and venous pH values (P < .05), and lower Apgar scores after 5 minutes (P < .01) as well as an increased likelihood of cesarean delivery because of fetal distress (P < .001). The number of fetuses in group 4 with a cord blood base deficit of less than -8 mmol/L was increased. Nucleated red blood cell counts were comparable in fetuses in group 2 (median, 5.4; range, 0-37) and group 1. In groups 1 to 3 no brain-sparing effect occurred, whereas in 15 of 21 cases in group 4 a brain-sparing effect was present. Multivariate analysis revealed that Doppler results of the umbilical artery, fetal aorta, and uterine arteries were independent determinants of neonatal nucleated red blood cell count. Increasing abnormalities seen on fetoplacental Doppler studies are associated with increasing numbers of nucleated red blood cells at birth. Given the known relationship between abnormal Doppler flow and intrauterine hypoxemia, the neonatal nucleated red blood cell count might become an additional valuable tool in the surveillance of growth-restricted fetuses.

Course and outcome of a pregnancy with a giant fetal cervical teratoma diagnosed prenatally.

We report the course and outcome of a pregnancy involving a giant fetal neck teratoma which was diagnosed at 23 weeks of gestation. Sonographic surveillance of the fetal neck revealed continuing growth of the tumor with development of polyhydramnios. Three-dimensional ultrasound provided additional detailed information on the external extent of the lesion. Color Doppler ultrasound showed intense arterial and venous flow with low resistance indices. Cesarean section under general anesthesia was planned in close cooperation with the neonatologist, pediatric surgeon and anesthesiologist because the size of the neck mass precluded vaginal delivery. Cesarean section was performed at 34 weeks of gestation following preterm rupture of the membranes. Orotracheal intubation was not successful because of compression of the airway and a tracheostomy could not be performed because of the risk of severe fetal hemorrhage from the tumor. The neonate died from respiratory insufficiency 66 min after birth.

Neonatal nucleated red blood cell counts in small-for-gestational-age fetuses: relationship to fetoplacental Doppler studies.

OBJECTIVE: To study the influence of pathologic umbilical and middle cerebral artery and uterine artery Doppler studies on the nucleated red blood cell count in small-for-gestational-age (SGA) fetuses. MATERIALS AND METHODS: Cord blood was prospectively collected during a 18-month period. 80 SGA fetuses (fetal abdominal circumference < 5th percentile) with Doppler ultrasound of the umbilical, the middle cerebral artery and both uterine arteries were enrolled in the study. SGA fetuses with normal Doppler flow velocity waveforms were allocated to group 1 (n = 23). Group 2 (n = 13) were fetuses with abnormal umbilical Doppler studies and group 3 (n = 44) were fetuses with both, pathologic umbilical and uterine artery Doppler studies. 2 fetuses in group 3 showed evidence of brain sparing, 3 fetuses presented absent-end-diastolic flow in the umbilical artery. Outcome measures included nucleated red blood cell count, Apgar scores, arterial pH and arterial base excess, venous pH, birth weight, gestational age at delivery, mode of delivery, rate of neonatal intensive care unit admission and length of stay in the neonatal intensive care unit. RESULTS: Highest nucleated red blood cell counts with lowest birth weight and gestational age were found in group 3. Decelerations of the fetal heart rate were more frequent in study group 3 and caesarean section for fetal indication was performed more often in this group. Those fetuses had to be transfered more often to the neonatal intensive care unit than fetuses of the other study groups. There was a tendency in group 3 towards lower arterial pH values and arterial base excess values. Fetuses with absent-end-diastolic flow in the umbilical artery presented highest nucleated red blood cell counts. CONCLUSION: In SGA fetuses increasing Doppler pathology seems to be correlated with increasing nucleated red blood cell count post-partum. Pathologic uterine artery flow results might have an additional impact on the number of nucleated red blood cells at birth.

[Effect of hypertensive pregnancy complications on neonatal outcome of growth retarded fetuses]. / Einfluss hypertensiver Schwangerschaftskomplikationen auf das neonatale Outcome wachstumsretardierter Feten.

OBJECTIVE: To determine the effect of hypertensive disorders in pregnancy on the neonatal outcome of growth restricted fetuses. There is conflicting data on the effect of hypertension during pregnancy on the incidence of neonatal respiratory distress syndrome (RDS) and intraventricular hemorrhage. Some studies report a lower incidence of RDS and intraventricular hemorrhage in infants of hypertensive mothers, whereas other studies report a similar or higher incidence in infants born to hypertensive mothers. STUDY DESIGN: We performed a retrospective analysis of 220 growth restricted fetuses born between January 1, 1996 to July 1, 1997 at the Department of Obstetrics and Gynecology of the University-Hospital at Homburg/Saar. Data were obtained by review of the medical records. Growth restricted infants born to preeclamptic women or women with HELLP syndrome were compared to growth restricted fetuses born to mothers without hypertensive disorders. RESULTS: Growth restricted fetuses born to hypertensive mothers had a significant lower birth weight (p < 0.05). The incidence of RDS in children born to hypertensive mothers was significantly higher (p < 0.05, p < 0.01) and they stayed significantly longer in the neonatal intensive care unit (p < 0.01). In contrast to infants born to mothers with HELLP syndrome (n = 7) there was no difference in the incidence of intraventricular hemorrhage, infection, sepsis, necrotizing enterocolitis or cardiac complications (arrhythmia, insufficiency) in case of preeclampsia (n = 68). The perinatal mortality of infants born to hypertensive mothers was significantly higher (p < 0.05, p < 0.01). CONCLUSION: This study does not support the contention that hypertensive disorders in pregnancy have a beneficial effect on the postnatal course of IUGR infants.

Maternal and neonatal outcome of twin pregnancies complicated by single fetal death.

OBJECTIVE: To study the maternal and neonatal outcome of twin pregnancies complicated by the intrauterine death of one fetus after 20 weeks of gestation. DESIGN: Retrospective, observational study of 7 twin pregnancies out of 185 twin pregnancies with the diagnosis of a single intrauterine death over a 5-years period in a university hospital. RESULTS: The incidence of single fetal death in twin gestation after 20 weeks was 3.8% in the study population with a high incidence of intrauterine growth retardation (IUGR) of the remaining fetus and preeclampsia in the further course of pregnancy. The incidence of preterm delivery was 71% with a mean gestational age of 33.0 +/- 1.0 weeks. The median interval from diagnosis of single fetal death to delivery was 10.2 +/- 4.1 days (range 1-28 days). 5 of 7 (71%) cases were delivered by cesarean section for standard obstetrical reasons. Neither perinatal nor neonatal death of the remaining twin were observed. Two cases of neurologic injury were diagnosed after delivery by ultrasound and MRI. No maternal coagulopathy related to single fetal death occurred. CONCLUSION: Expectant management of single fetal death in twin pregnancies might be advisible under close surveillance of both, mother and the surviving fetus.

Nucleated red blood cells in cord blood of singleton term and post-term neonates.

OBJECTIVE: This study aims to determine if nucleated red blood cells are elevated in pregnancies that continue beyond 289 days of gestation. STUDY DESIGN: Cord blood was prospectively collected from term and post-term singleton gestations from August 1 to December 31, 1998. Umbilical artery nucleated red blood cells were counted per 100 white blood cells. The comparison was made between pregnancies ending at 261-289 days (37.1-41.2 weeks) of gestation and those ending after 289 days (> or = 41.3 weeks) of gestation. RESULTS: Cord blood from 304 cases was obtained and evaluated for nucleated red blood cells per 100 white blood cells. The mean value of nucleated red blood cells per 100 white blood cells in the post-term neonate group was significantly higher than in the term neonate group (median 6.5, range 0-24 vs. median 3.7, range 0-14; p < 0.05). The values did not vary by fetal presentation, mode or duration of delivery. Neonatal outcome was comparable between both study groups. CONCLUSION: In post-term gestation after 289 days nucleated red blood cells in cord blood are significantly increased. These results point towards a different fetal oxygenation in post-term pregnancies beyond 289 days of gestation and support the current practice of very close testing of fetal well-being under those circumstances.