Conservative medical management of advanced cervical ectopic pregnancies.

Cervical ectopic pregnancy is the rarest form of ectopic gestation. Viable cervical ectopic pregnancies of 10 weeks' gestation or more are even rarer. It is unclear whether these advanced cervical ectopic gestations should be managed primarily by surgical evacuation or by more conservative medical management with chemotherapeutic agents. Cases of medical treatment of viable cervical ectopic gestations reported in the literature are reviewed. An additional case of a 10.6 weeks of gestation, viable cervical ectopic pregnancy treated with methotrexate, intrafetal potassium chloride, and intramuscular methotrexate is added to the previously reported literature. Advanced cervical ectopic pregnancies with fetal cardiac activity at 10 or more weeks' gestation may be successfully managed with chemotherapeutic agents. Ultrasound-guided intrafetal injection of feticidal agents may be preferable to maternal systemic chemotherapy alone.

Prenatal diagnosis of fatal infantile olivopontocerebellar hypoplasia syndrome.

We report the first case of prenatal diagnosis of fatal infantile olivopontocerebellar hypoplasia syndrome, OMIM 225753. Ultrasound findings noted at 28 weeks' gestation included polyhydramnios, a small stomach bubble, a small but morphologically normal cerebellum, dilatation of the fourth ventricle, and long periods of normal fetal movement punctuated by sudden bursts of violent seizure-like activity of the fetal extremities. At birth, the child was noted to be hypertonic, myoclonic, hyper-reflexic, demonstrated poor gastrointestinal motility, and had severe apneic episodes. Magnetic resonance imaging (MRI) demonstrated marked hypoplasia or atrophy of the cerebellum, pons and medulla, mild atrophy of the cerebral cortex, and mild ex vacuo venticulomegaly of the fourth, third and lateral ventricles. This child died from respiratory insufficiency at 14 days of age. The parents of this child had previously lost a child with similar clinical and anatomical findings. Prenatal sonographers should be aware of the existence of this rare syndrome and should look carefully at the size of the cerebellum in cases of polyhydramnios or when in utero 'seizure-like' activity is seen. The importance of establishing this diagnosis lies in the fact that it appears to have a very poor postnatal prognosis and is likely to be inherited as an autosomal recessive disease.

A randomized, prospective study comparing once-daily gentamicin versus thrice-daily gentamicin in the treatment of puerperal infection.

OBJECTIVE: The efficacy, safety, and antibiotic-related charges for once-daily gentamicin with twice-daily clindamycin were compared with those of thrice-daily dosing of these antibiotics. STUDY DESIGN: Patients with puerperal endometritis or with chorioamnionitis in labor assessed to be at risk for endometritis were randomized to receive gentamicin 4 mg/kg intravenously every 24 hours with clindamycin 1200 mg intravenously every 12 hours (experimental arm) or gentamicin 1.33 mg/kg intravenously and clindamycin 800 mg intravenously every 8 hours (conventional dosing interval arm). Primary outcomes included cure rates, mean length of treatment, antibiotic-related charges, and nephrotoxicity. Multiple logistic regression analysis was used to control for confounding variables. RESULTS: There were 135 and 137 patients randomized to the experimental and conventional interval arms, respectively. Cures were obtained in 94.1% and 87.6% of patients in the experimental and conventional arms, respectively (p = 0.06). The experimental arm had mean antibiotic charges of $250.79 versus $442.49 in the conventional arm (p < 0.0001). There was no permanent nephrotoxicity in either group. CONCLUSIONS: Once-daily gentamicin dosing with twice-daily clindamycin dosing is as efficacious and safe as the thrice-daily dosing of gentamicin and clindamycin for peripartum uterine infection. The experimental regimen results in substantial cost savings. The incidence of nephrotoxicity is low.

Transvaginal versus transabdominal Doppler auscultation of fetal heart activity: a comparative study.

OBJECTIVE: Our purpose was to determine whether transvaginal Doppler auscultation is more sensitive than transabdominal auscultation for the detection of fetal heart rate in the first trimester of pregnancy. STUDY DESIGN: In a prospective study 141 patients between 6 weeks and 11 weeks 6 days of gestation underwent both transvaginal and transabdominal Doppler evaluation by use of continuous-wave Doppler instruments for detection of fetal heart rate. Transvaginal ultrasonography was used as the gold standard to establish fetal cardiac activity and to help assign gestational age. The two methods of auscultation were compared for accuracy in different gestational age ranges. Sensitivities and specificities were calculated, and associations were investigated with chi 2 analysis. The direction of disagreement between modalities was tested with the McNemar chi 2 test. RESULTS: Transvaginal auscultation outperformed transabdominal auscultation in every gestational age range. Transvaginal Doppler auscultation performed significantly better than transabdominal Doppler auscultation at 8 weeks to 8 weeks 6 days (p < or = 0.004) and 9 weeks to 9 weeks 6 days (p < or = 0.006). In pregnancies with cardiac activity, fetal heart rate can be successfully detected transvaginally in 60.5% of pregnancies at 8 weeks to 8 weeks 6 days and in 87.5% of pregnancies at 9 weeks to 9 weeks 6 days of gestation. This compares with successful transabdominal detection rates of 22.9% and 56% at 8 and 9 weeks, respectively. As gestational age advances both methods became increasingly sensitive for the detection of fetal heart rate. The earliest fetal heart rate detected transvaginally was at 6 weeks 0 days of gestation compared with 7 weeks 0 days transabdominally. The transvaginal Doppler method was also more successful in detecting the fetal heart rate in women with a retroverted uterus (p < or = 0.01). CONCLUSION: By use of continuous-wave Doppler instrumentation, transvaginal auscultation is significantly better than transabdominal auscultation in detecting fetal heart rate between 8 weeks to 8 weeks 6 days and 9 weeks to 9 weeks 6 days of gestation. Use of transvaginal auscultation has potential in the evaluation of first-trimester fetal cardiac activity.

Pregnancy in a patient with eosinophilic granulomatosis of the lung: a case report.

BACKGROUND: There are three syndromes of histiocytosis X: eosinophilic granulomatosis of the lungs, Hand-Schüller-Christian disease, and Letterer-Siwe disease. Although there have been five case reports of Hand-Schüller-Christian disease in pregnancy, we found none describing pregnancy in patients with eosinophilic granulomatosis. CASE: We present a report of eosinophilic granulomatosis of the lungs in pregnancy. The patient's pregnancy was complicated by fetal growth retardation (FGR) and oligohydramnios, but resulted in the delivery of a healthy infant. Her pulmonary disease remained stable. CONCLUSION: Pregnancy does not appear to exacerbate pulmonary eosinophilic granulomatosis. In this patient, pregnancy was complicated by FGR and oligohydramnios. This case report may be valuable in counseling patients with eosinophilic granulomatosis who are currently pregnant or contemplating pregnancy.

Spontaneous resolution of hypofibrinogenemia in a triplet gestation associated with second trimester in utero death of two fetuses.

Multiple gestations are increasing in frequency secondary to assisted reproductive technologies; therefore, it will become increasingly important to know how to manage a multiple pregnancy in which an in utero fetal death has occurred. This case report describes the spontaneous resolution of maternal hypofibrinogenemia associated with the deaths of two fetuses in a triplet gestation. A 29-year-old woman with a triplet gestation had in utero death of two monoamniotic fetuses between 15 and 17 weeks' gestation. Maternal plasma fibrinogen levels were obtained weekly and were initially in the normal range for pregnancy. At 31 weeks' gestation, the fibrinogen level decreased to 239 mg/dl and reached a nadir of 150 mg/dl 11 days later. Although the patient received no treatment, her fibrinogen level increased to 307 mg/dl over the next 4 days and then remained above 260 mg/dl for the rest of her pregnancy. At 35 weeks' gestation, a healthy 2090 gm female was delivered. The infant is alive and well and developing normally. When there is an in utero death of one fetus of a multiple gestation in the second or early third trimester, some authors advocate heparinization to reverse maternal coagulopathy; others describe spontaneous resolution of hypofibrinogenemia. The role of heparin in treating hypofibrinogenemia remains unclear. Hypofibrinogenemia may resolve spontaneously without exposing the patient to the potentially serious risks associated with heparin therapy.

The role of calcium in the modulation of the hepatic anti-oxidant defence system.

A normocalcemic animal model of vitamin D (vit. D)-deficiency has been successfully developed by feeding a high calcium (Ca2+) diet to vit. D.-deficient rats. The modulating role of Ca2+ on the hepatic antioxidant defence system and lipid peroxidation has been evaluated in this model. Partial restoration of liver function was noted in these rats following extra Ca2+ feeding. Serum alkaline phosphatase and alanine aminotransferase reverted to a normal level. The reduced levels of hepatic SOD and glutathione peroxidase in vit. D.-deficient rats, were also increased after extra Ca2+ supplementation. Even elevated lipid peroxidation due to vit. D.-deficiency was reduced after feeding the extra Ca(2+)-supplemented diet. However, catalase activity remained at the control level throughout the study. The results provide important evidence that normocalcemia is essential for maintaining the hepatic antioxidant defence and controlling lipid peroxidation in the in vivo milieu.

Emergency cerclages: a review of 40 consecutive procedures.

This report describes 40 consecutive emergency cerclages on dilated and effaced cervices prior to 26 weeks' gestation. These "emergency" cerclages were associated with a mean extension of gestational age of 12 weeks (range, 3 days to 20.5 weeks). Thirty-one of 40 pregnancies were carried to 28 weeks' gestation and 23 were carried to 34 weeks' gestation or greater. Twelve of 19 women with amniotic membranes bulging into the vagina carried pregnancies to 28 weeks' gestation, with seven of these 19 women carrying the gestation to 34 weeks' or beyond. There was no maternal morbidity. Thirty-four of 41 infants survived (83%). Two pregnancies delivered within 8 days of the procedure. Emergency cerclages should be considered as a management option in women with painless dilation of the cervix and previable gestation.