Prenatal aspects of giant fetal cranial haemangio-endothelioma

A case of a large vascular lesion of the skull is reported. The lesion was discovered at 22 weeks' gestation and it rapidly increased in size, reaching 8 cm a month later. Tumor echogenicity was the same as that for soft tissues and colour Doppler examination revealed intense vascularization. Cordocentesis showed features of the Kasabach-Merritt syndrome and very high plasma levels of alpha-fetoprotein. A Caesarean section was performed to avoid dystocia and led to the birth of a baby with cardiac failure in the immediate neonatal period. Biopsies of the mass led to the diagnosis of a non-malignant haemangio-endothelioma. The mass was removed and plastic surgery performed. The baby is alive and well 9 months after the operation.

[Intrauterine growth retardation]

Intrauterine growth retardation is an important cause of perinatal death. The etiology is predominantly renovascular-syndromes, chromosome or genetic anomalies, and idiopathic hypotrophy. The small for age baby is hypoxic and hypercapnic, with acidosis. Fetal circulation is redistributed to protect the brain. The type of retarded growth (well balanced? or not), its severity and its potential development can be evaluated by echographic examination, and means of Doppler study. The only treatment is fetal removal. The date of this removal is a compromise between the risk of fetal death or neurological consequences of prolonged hypoxia on the one hand, and of the risk of severe iatrogenic prematurity, or neonatal death, if removal is made at too young a gestational age. The only preventive treatment that has been evaluated is lowdose aspirin which, in at-risk patients, has reduced the risk by a factor of four to six.

Weight excess before pregnancy: complications and cost

OBJECTIVE

To investigate the incidence of pregnancy complications and the cost of prenatal care in patients with pregravid overweight.

DESIGN

Retrospective study of patients dispatched into four groups: normal weight, moderate overweight, obesity, massive obesity.

SETTING

Department of Obstetrics and Gynecology of Montpellier.

SUBJECTS

One hundred and twelve pregnancies among 89 overweight women, compared with 54 healthy normal weight controls.

MAIN OUTCOME MEASURES

Incidence of maternal complications, complications of labor, duration of hospitalization.

RESULTS

Hypertension, toxemia, gestational diabetes, insulin treatment, urinary tract infections and macrosomia were positively correlated with maternal pregravid weight excess. Mean duration of hospitalization and overall cost were also strongly related to maternal weight. Cesarean section rate increased only in morbidly obese women. No materno-fetal mortality was observed in our study.

CONCLUSION

Even moderate overweight is a significant risk factor for obstetrical complications and needs a multidisciplinary antenatal management in order to prevent materno-fetal complications.

Red blood cell vitamin E concentrations in fetuses are related to but lower than those in mothers during gestation. A possible association with maternal lipoprotein (a) plasma levels

OBJECTIVE

The purpose was to establish which blood characteristic of vitamin E status were highly correlated between mothers and fetuses during gestation.

STUDY DESIGN

Twenty-four pregnant women were selected because of suspicion of toxoplasmosis or other disease and malformation or intrauterine growth delay justifying cord blood puncture. After maternal and fetal blood was collected, analyses of plasma and red blood cell vitamin E contents were performed together with analyses of standard lipid parameters and lipoprotein (a) in maternal plasma and fatty acid compositions of maternal and fetal red blood cells.

RESULTS

The maternal population was characterized by a plasma lipid-normalized vitamin E mean content higher (3.5 mmol/mol lipids) than usually found in nonpregnant adults. There was no relationship between plasma and red blood cell vitamin E contents. This was also true for fetuses. When the vitamin E status of mothers was compared with that of fetuses, we found no correlation in plasma vitamin E in the whole population and in the high lipoprotein (a) (> 300 mg/L) and low lipoprotein (a) (< 300 mg/L) groups. In contrast, statistically significant correlations appeared between maternal and fetal red blood cell contents and red blood cell relative charges in vitamin E in the whole population, whereas still higher correlations occurred in the high lipoprotein (a) group (r = 0.94 for the red blood cell content). Improved correlations were also found in the high lipoprotein (a) group for the interrelationship between vitamin E and plasma lipid contents (cholesterol and triglycerides), whereas improvement was noted in the low lipoprotein (a) group by positive correlation between age and vitamin E red blood cell content or red blood cell relative charge.

CONCLUSION

Determination of red blood cell vitamin E and plasma lipoprotein (a) in mothers could be useful in antenatal blood analysis in cases of risk of prematurity at birth, to prevent peroxidative membrane damage in neonates, and > 85% of the mothers in the current population would benefit from vitamin E supplementation from the viewpoint of the fetal red blood cell vitamin E requirement in spite of the rather high maternal lipid-normalized vitamin E plasma content.

Amniocentesis before 15 weeks' gestation: technical aspects and obstetric risks

In a prospective case-control study, early amniocenteses (EAC, n = 242) at between 12 and 14 weeks gestation, were compared with standard amniocenteses (SAC, n = 242) performed at between 15 and 24 weeks gestation. The medical records of these 484 cases were reviewed for indications, success rate, color and volume of amniotic fluid, gestational age, number of needle insertions, location of the placenta, culture failure rate, obstetric complications and therapeutic abortion rate. There were no significant differences between the two groups in success rate, in culture success rate or in the outcome of the pregnancies. The volume of the sample taken was smaller in the EAC patients (P < 0.001), and therapeutic abortions were performed significantly earlier (P < 0.02.) Results show that EAC is feasible from 11 weeks' gestation, and can be performed for the usual indications as an alternative to chorionic villus sampling. In the near future, cytogenetic techniques will enable results to be obtained in less than a week.

Scanning gel densitometry of amniotic fluid acetylcholinesterase and butyrylcholinesterase: quantification of 'faint-positive' bands in fetal malformations

The quantification of 'faint-positive' cholinesterases in amniotic fluid was performed in 40 patients with positive acetylcholinesterase (AchE) tests. Fetuses with anencephaly and open spina bifida presented an AchE/butyrylcholinesterase (A/B) ratio of more than 0.3 with clearly dense bands. Fetuses with gastroschisis showed a 'faint-positive' AchE band (A/B < 0.3). In 5 fetuses (1 teratoma, 3 open spina bifida, 1 unaffected) we found faint AchE and butyrylcholinesterase bands.

Fetal diagnosis of toxoplasmosis in 190 women infected during pregnancy

One hundred and ninety women who contracted toxoplasmosis after the seventh week of pregnancy underwent antenatal diagnosis, including ultrasound examination and biological tests. Tests included Toxoplasma isolation in fetal blood and amniotic fluid by mouse inoculation, specific IgM and IgA in fetal blood, and non-specific tests. Twenty fetuses had positive specific as well as non-specific tests for Toxoplasma infection. At birth, four of these presented with clinical congenital toxoplasmosis and 12 with subclinical forms. Antenatal diagnosis enabled the detection of 83 per cent of the infected fetuses. Under specific conditions, cordocentesis permits early diagnosis and considerably reduces the number of terminations of pregnancy.

[Obstetrical complications of maternal overweight]

Overweight is associated with a higher risk of cardiovascular and metabolic disease. Pregnancy in obese women frequently results in an increased incidence of maternal complications (gestational diabetes, hypertension, toxemia) and adverse perinatal outcome (macrosomia, perinatal mortality). Cesarean deliveries are also more frequent in obese women, mainly because of cephalopelvic dysproportion due to macrosomia. Optimal treatment for gestational diabetes is difficult to achieve, although hyperglycemia further impairs maternofoetal prognosis. The incidence of intrauterine growth retardation is not increased in obese pregnancy. A successful obstetrical outcome may be achievable through multidisciplinary antenatal management.

Prenatal diagnosis of a multifocal lymphangioma

Lymphangiomas or cystic hygromas are malformations of the lymphatic vessels and are characterized by single or multiple cysts which have developed within the soft tissues. They occur most commonly in the neck (75 per cent of cases) and are often associated with hydrops or chromosomal abnormalities (Romero et al., 1988). Mediastinal or abdominal locations are rare and represent less than 5 per cent of cases in the literature (Singh et al., 1971). This paper represents the first reported case of prenatal diagnosis of a lymphangioma in the neck, mediastinum, and abdomen. Diagnosis was made before fetal viability, and allowed us to recommend termination of the pregnancy because of the poor prognosis.

Effects of selective reduction in triplet gestation: a comparative study of 80 cases managed with or without this procedure

OBJECTIVE

To evaluate the effect of selective termination in triplet pregnancies.

DESIGN

Comparative, prospective, nonrandomized study.

SETTING

All 80 pregnancies were managed in a single tertiary center by the same obstetrical team.

PATIENTS

Eighty women with triplet pregnancies were divided into two groups: group I consisted of 48 women who wished to continue their pregnancies without reduction; in group II were 32 women who choose reduction generally to obtain twins.

INTERVENTIONS

Selective terminations were performed after an average term of 9.6 weeks of gestation by transcervical or transabdominal approaches.

MAIN OUTCOME MEASUREMENTS

The rate of miscarriage and prematurity, fetal growth, perinatal morbidity and mortality, and maternal complications in the two groups.

RESULTS

Prematurity was lower in reduced pregnancies (95.5% in triplets versus 53.5%), especially between 24 to 32 weeks' gestation where prematurity was reduced by half. Birth weight was > 450 g higher in the reduced group. The perinatal mortality rate was lower for reduced pregnancies, but this difference was not statistically significant. Five life-threatening maternal complications occurred in triplets, with none in the reduced group.

CONCLUSIONS

Selective terminations are effective in decreasing the rate of prematurity, improving fetal growth, and avoiding maternal complications. The procedure thus could be used in triplet gestations. The ultimate decision should be taken by the couple who must be well informed of the risks of the procedure before deciding.

Fetal hemangiolymphangioma: a case report

Hemangiolymphangioma is a malformation of both lymphatic and blood vessels. We present a case of fetal abdominal hemolymphangioma diagnosed by ultrasound at 27 weeks of gestation. The extensive fetal involvement, and the diagnosis before fetal viability led us to propose medical termination of pregnancy. This represents the second reported case of prenatal diagnosis of this malformation.

Hematologic values of fetal blood obtained by means of cordocentesis

Fetal blood values were evaluated from 541 cordocenteses. Simple regressions were used to find a correlation between blood values and gestational age. We found a linear increase in hemoglobin concentration and hematocrit throughout gestation; a linear decrease of the mean corpuscular volume with the gestation was evidenced as a regular decrease in mean corpuscular hemoglobin. Lastly, the mean corpuscular hemoglobin concentration was constant during the gestation; a linear increase of the platelet count and the nucleated cells was also evidenced. We suggest that each fetal medicine unit should have its own reference ranges. It will permit to accurately diagnose fetal infection, fetal anemia, or any fetal disease where alterations of hematopoiesis have been described.

Multifetal pregnancy reduction: a consecutive series of 61 cases

OBJECTIVE

The effect of selective fetocide on the course of 61 multiple pregnancies.

DESIGN

An observational study.

SETTING

A tertiary centre.

SUBJECTS

61 women whose pregnancies included 37 triplets, 18 quadruplets, 5 quintuplets and 1 hepatuplet; 97% followed IVF or the induction of ovulation. The aim of the procedure in most cases was to obtain twins.

INTERVENTIONS

Selective reduction was performed before 13 weeks gestation under general anaesthesia, using either a transcervical (n = 26) or transabdominal approach (n = 35). Fifty-four twins, 4 singletons and 3 triplets were obtained after the procedure.

MAIN OUTCOME MEASURE

Preterm labour rate.

RESULTS

The rate of unplanned fetal loss was 13% and was related to the number of suppressed embryos (P < 0.05). The preterm labour rate was 56.6%, the mean gestation at delivery was 35.6 weeks. Seven deliveries were before 32 weeks and led to all neonatal deaths. A comparison with published data suggested that fetal reduction reduced the rate of preterm labour in high multiple pregnancies; in 24 twin pregnancies obtained after reduction of triplets there was probably a gain of 2 weeks gestation. Severe growth retardation occurred in 13%. The perinatal mortality rate was 10.8%.

CONCLUSIONS

Selective termination reduces but does not prevent early preterm labour. The procedure is of value in pregnancies with more than 3 fetuses and should be considered carefully for triplet pregnancies.

Prenatal diagnosis of diastematomyelia

Fetal diastematomyelia, a malformation due to a longitudinal split of the cord, was diagnosed during the third trimester. Diagnosis was based on the visualization of a sagittal bony spur in the thoracolumbar spinal canal, associated with enlargement of the canal, hemivertebrae and spina bifida without a meningocele.

Late vaginal induced abortion after a previous cesarean birth: potential for uterine rupture

This descriptive study was conducted to evaluate the risk of uterine rupture in cases of late vaginal induced abortions among women with previous cesarean sections. 23 women were referred at a mean gestational age of 23.9 (SD 6.9) weeks of gestation after one or two cesarean sections. Indications for terminating the pregnancy were maternal diseases in 4 cases and fetal anomalies in 19 cases. RU 486 and/or prostaglandins were used for cervical ripening and to induce labor. Vaginal birth was obtained in 20 cases (86.9%) with an average duration of 72 (SD 52) h. Cesarean section was performed in the remaining 3 women because no cervical dilation could be obtained. One uterine rupture occurred and was treated with conservation of the uterus. Late termination of pregnancy in such cases can be achieved without cesarean section with a high success rate.