Absence of Ductus Venosus: A Comparison of 2 Distinctive Fetal Autopsy Cases and Embryologic Perspectives

In fetal circulation, oxygenated blood from the placenta flows through the umbilical vein into the ductus venosus (DV), then enters the inferior vena cava, and subsequently reaches the right atrium of the heart. The DV serves as a shunt, allowing this oxygen-rich blood to bypass the liver. The absence of the DV (ADV), also known as agenesis of the DV, is a rare congenital anomaly. Without a DV, blood from the umbilical vein must follow alternative routes to the heart. In ADV cases, blood from the umbilical vein must follow 1 of 2 primary drainage patterns: either an extrahepatic shunt or an intrahepatic shunt. This report details the antenatal ultrasound and postmortem findings of 2 fetuses diagnosed with ADV by prenatal imaging studies. The first case involved a fetus with a persistent right umbilical vein connected directly to the suprahepatic IVC, accompanied by early obliteration of the left umbilical vein and true agenesis of the DV. This fetus also had additional congenital anomalies. In contrast, the second case involved a fetus with a normal left umbilical vein that entered the liver. However, despite an ultrasound diagnosis of "absence" of the DV, a DV was present, though markedly hypoplastic and probably minimally functional or non-functional. In this case, blood from the umbilical vein likely followed an alternate intrahepatic route through the portal and hepatic veins, before reaching the heart (intrahepatic shunt). These contrasting cases emphasize the heterogeneity of vascular anomalies and embryologic origins captured by the term "ADV." Additionally, the terminology of "absence" or "agenesis" may be misleading in some purported ADV cases. Specifically, in the second case, the DV was not absent; it was markedly hypoplastic instead. This also appears to be the first reported case of a hypoplastic DV in a fetus. Both cases underscore the importance of effective collaboration and clear communication between maternal-fetal medicine specialists and pathologists.

Maternal Hemoglobin A1c in the Third-Trimester May Underestimate Maternal Hyperglycemia and Its Impact on Offspring in Perinatal Demise Associated With Gestational Diabetes Mellitus: An Autopsy Case Series

INTRODUCTION

Gestational diabetes mellitus (GDM) is a common metabolic disorder linked to adverse pregnancy outcomes. Recent research indicates that HbA1c is reliable in detecting maternal glycemia during the first trimester but may underestimate glucose intolerance in the late second to third trimesters. Therefore, it is reasonable to hypothesize that mothers with GDM, despite apparently normal HbA1c levels in the third trimester, may give birth to infants displaying characteristic features often seen in infants of diabetic mothers with suboptimal glycemic control. This study aimed to describe a case series of autopsy cases involving stillborn or deceased neonates delivered in the third trimester to mothers diagnosed with GDM and having normal HbA1c levels at or around the time of delivery. The primary focus was on identifying and documenting the characteristic features commonly associated with "infants of diabetic mothers" with suboptimal glycemic control in this series of cases.

MATERIALS AND METHODS

We conducted a retrospective review of autopsy reports from our institution spanning 7.5 years. The study included cases that met the following criteria: (1) stillborn or infants who died in the early neonatal period, delivered in the third trimester; (2) mothers diagnosed with GDM; (3) normal maternal HbA1c levels of ≤6.1% at or around the time of delivery; (4) birthweight or femoral length exceeding the 90th percentile for gestational age; and (5) absence of genetic aberrations. We also examined these cases for other characteristic features associated with "infants of diabetic mothers."

RESULTS

Ten autopsy cases met our inclusion criteria, including 9 stillbirths and 1 neonatal death. Gestational age at delivery ranged from 32 to 39 weeks (mean: 35.7 weeks). Femoral length exceeded the 90th percentile in all cases, and 6 cases had birthweights above the 90th percentile. Puffy facies were observed in 6 cases. Among the 9 cases with complete autopsies including internal examination, 6 exhibited excess adipose tissue, 4 had cardiomegaly, and 3 showed pancreatic islet hyperplasia. Hypoxic-ischemic encephalopathy was detected in 7 cases. No structural abnormalities were noted.

DISCUSSION

Our findings demonstrated that fetuses and neonates born to mothers with apparently normal HbA1c levels in the third trimester could still display characteristic features commonly observed in infants of diabetic mothers with poor glycemic control, also known as "infants of diabetic mothers." This study underscores the potential of third-trimester maternal HbA1c measurements to underestimate maternal glycemia and its consequential impact on fetal development, as well as the subsequent manifestation of features of "infants of diabetic mothers."

C4d Staining Is Present in Normal Placentas From Pregnancies Prior to Pregnancy Loss Associated With Chronic Histiocytic Intervillositis and Is Reduced by Immunomodulatory Therapy in Subsequent Pregnancies

INTRODUCTION

Chronic histiocytic intervillositis (CHI) is associated with adverse pregnancy outcomes and high recurrence risk. Recent studies suggest that CHI may represent a host-vs-graft rejection, and that C4d immunostain can be used as a marker for complement activation and antibody-mediated rejection in the CHI.

MATERIALS AND METHODS

This retrospective cohort study focused on 5 fetal autopsy cases associated with CHI (5 index cases) from 5 women. We analyzed placentas from the index cases (fetal autopsy cases associated with CHI) and placentas from the women's previous and subsequent pregnancies. We assessed the presence and extent of CHI and C4d immunostaining in these placentas. We evaluated each available placenta and graded the severity of CHI as either <50% or ≥50%. Additionally, we conducted C4d immunostaining on one representative section from each placenta and graded the staining levels as follows: 0+ for staining <5%; 1+ for staining between 5% and <25%; 2+ for staining between 25% and <75%; and 3+ for staining ≥75%.

RESULTS

Three of the 5 women had pregnancies prior to their index cases (fetal autopsy cases associated with CHI). Despite the absence of CHI in their initial pregnancies, the placentas displayed positive C4d staining with grades of 1+, 3+, and 3+, respectively. These results suggest the presence of complement activation and antibody-mediated rejection in placentas from their prior pregnancies without CHI. Three of the 5 women received immunomodulatory therapy after experiencing pregnancy losses associated with CHI. After treatment, 2 of these women had live births at 35 and 37 gestational weeks, respectively, while the third had a stillbirth at 25 gestational weeks. The severity of CHI and the degree of C4d staining in the placentas decreased in all 3 cases following immunomodulatory therapies. Specifically, the level of C4d staining decreased from 3+ to 2+, 2+ to 0+, and 3+ to 1+ in these 3 cases, respectively.

DISCUSSION

In women with a history of recurrent pregnancy loss associated with CHI, C4d immunostaining was present in the placentas from their previous non-CHI pregnancies, suggesting activation of the classical complement pathway and antibody-mediated reaction in their prior non-CHI pregnancies before the development of CHI in subsequent pregnancies. Immunomodulatory therapy may improve pregnancy outcomes by reducing complement activation, as shown by the reduction of C4d immunopositivity in the placentas after immunomodulatory treatment. Although we believe that the study provides valuable insights, we acknowledge that there are limitations to the findings. Therefore, to further elucidate the pathogenesis of CHI, additional research efforts with a collaborative and multidisciplinary approach are necessary.

Treatment and Outcomes of Congenital Ovarian Cysts A Study by the Canadian Consortium for Research in Pediatric Surgery (CanCORPS)

OBJECTIVE

We conducted a multicenter study to assess treatments and outcomes in a national cohort of infants with congenital ovarian cysts.

SUMMARY BACKGROUND DATA

Wide variability exists in the treatment of congenital ovarian cysts. The effects of various treatment strategies on outcomes, specifically ovarian preservation, are not known.

METHODS

Female infants diagnosed with congenital intra-abdominal cysts between 2013 and 2017 at 10 Canadian pediatric surgical centers were retrospectively evaluated. Sonographic characteristics, median time to cyst resolution, incidence of ovarian preservation, and predictors of surgery were evaluated. Subgroup analyses were performed in patients with complex cysts and cysts ≥40 mm in diameter.

RESULTS

The study population included 189 neonates. Median gestational age at diagnosis and median maximal prenatal cyst diameter were 33 weeks and 40 mm, respectively. Cysts resolved spontaneously in 117 patients (62%), 14 (7%) prenatally, and the remainder at a median age of 124 days. Intervention occurred in 61 patients (32%), including prenatal aspiration (2, 3%), ovary sparing resection (14, 23%), or oophorectomy (45, 74%). Surgery occurred at a median age of 7.4weeks. Independent predictors of surgery included postnatal cyst diameter ≥40 mm [odds ratio (OR) 6.19, 95% confidence interval (CI) 1.66-35.9] and sonographic complex cyst character (OR 63.6, 95% CI 10.9-1232). There was no significant difference in the odds of ovarian preservation (OR 3.06, 95% CI 0.86 -13.2) between patients who underwent early surgery (n = 22) and those initially observed for at least 3 months (n = 131).

CONCLUSIONS

Most congenital ovarian cysts are asymptomatic and spontaneously resolve. Early surgical intervention does not increase ovarian preservation.

Differentiating congenital ovarian cysts from other abdominal cystic lesions in female infants: A study by the Canadian Consortium for Research in Pediatric Surgery (CanCORPS)

PURPOSE

The origin of congenital abdominal cysts in the female fetus often dictates management. While most arise from the ovary and are often managed non-operatively, some are non-ovarian and are frequently removed. We analyzed a national sample of female infants with congenital abdominal cysts to elucidate prenatal and postnatal factors associated with the diagnosis of a non-ovarian cyst.

METHODS

A retrospective cohort study of female infants who were prenatally diagnosed with abdominal cysts between 2013 and 2017 at 10 Canadian pediatric surgical centres was performed. Clinical characteristics, pre- and postnatal sonographic findings, and cyst trajectories were compared between patients with proven ovarian etiology and those with cysts arising from other organs.

RESULTS

Of 185 infants with prenatally diagnosed abdominal cysts, 22 (12%) were non-ovarian, five of which had clear non-ovarian organ of origin on prenatal ultrasound. Comparison of the other 17 cysts with 163 congenital ovarian cysts showed the following factors to be associated with a non-ovarian origin: earlier gestational age at diagnosis (23.5 vs 33.5 weeks, p <0.001), smaller diameter on first prenatal ultrasound (15.8 vs. 39.7 mm, p <0.001), change in sonographic character from simple to complex (87% vs 22%, p <0.001), and postnatal sonographic characteristics of complex cyst (87% vs. 48%, p = 0.004).

CONCLUSION

Clear organ of origin, diagnosis earlier in gestation, smaller initial prenatal cyst diameter, and sonographic cyst character change differentiate congenital non-ovarian cysts from their ovarian counterparts. These characteristics may be used to guide diagnosis and management.

Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC) in pregnancy: a case series of nine patients and review of literature

Background: Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a genetic cardiomyopathy characterized by myocardial necrosis and fibrofatty substitution of the myocardium, predominantly of the right ventricle. The evaluation of risk associated with gestation and delivery in patients with ARVC is difficult due to the small number of already reported cases. We present our experience of patients with ARVC who completed a pregnancy and delivery.Methods: A case series of nine women in Calgary, Canada, from 2013 to 2018, who were diagnosed with ARVC before or during pregnancy. Patients were identified using our Cardiac-Obstetrics database, and information was collected through electronic charts and patient recollection.Results: All pregnancies reported were singleton with an average maternal age of 31 years. Six patients had a related genetic mutation. Beta blockers were being used by eight, and five had an implantable cardioverter-defibrillator (ICD) prior to the pregnancy. None of the patients developed heart failure during pregnancy, but one had a complicated antepartum and postpartum course. All pregnancies delivered at term with eight receiving neuroaxial analgesia. Five patients delivered vaginally. Those without an ICD had continuous cardiac monitoring intrapartum. The incidence of small for gestational age (33%) was higher than the general population. All of the patients breastfed the newborns.Conclusions: Pregnancies in these patients with ARVC were generally well tolerated. Given the rarity of the disease and absence of any clinical guidelines, multidisciplinary care is essential in the management of these patients.

Atypical Prenatal Ultrasound Presentation and Neuropathological Findings in a Neonate With Alpha Thalassemia Major: A Case Report

Alpha thalassemia major is a hemoglobinopathy caused by the inactivation or deletion of all 4 α-globin alleles. We describe a case of α-thalassemia major with atypical ultrasound and neuropathological findings. The mother had her first prenatal visit at 27 4/7 gestational weeks. Ultrasound revealed a hydropic fetus with multiple anomalies. However, the middle cerebral artery peak systolic velocity (MCA-PSV) suggested that the likelihood of fetal anemia was low. Given the poor prognosis of hydrops fetalis, the parents opted for termination of pregnancy. The neonate died shortly after birth. Autopsy revealed a markedly hydropic female infant with severe limb reduction defects and, in contrast to what was suggested by the prenatal MCA-PSV measurement, unequivocal signs of severe anemia. The brain showed diffuse white matter gliosis. Genetic testing subsequently identified HBA1 and HBA2 deletions, consistent with α-thalassemia major. This case highlights the potential pitfall of MCA-PSV, which is nowadays considered the gold standard for noninvasive detection of fetal anemia. In addition, this is 1 of 2 published case reports detailing neuropathological findings in a fetus or neonate with α-thalassemia major and the first to link α-thalassemia major with diffuse white matter gliosis.

Can we predict and prevent emergency department visits for postpartum hypertensive complications in patients with hypertensive disorders in pregnancy?

Background: Hypertensive disorders of pregnancy are major causes of maternal mortality and morbidity, and postpartum hypertensive complications have significant implications on maternal health and public health care system. Antepartum community care programs for hypertension are in place at major centers of Canada, however, such a program for postpartum are usually lacking, and could be a cost-effective solution to reduce postpartum hypertensive complications.Objectives: To assess the proportion of women who present to the emergency department (ED) or outpatient clinics for postpartum hypertensive (PPHTN) complications up to 6 weeks postpartum, among pregnancies complicated by antenatal hypertensive disorders in Calgary, Canada. Secondary objectives were to identify risk factors for PPHTN complications, and to perform a cost-benefit analysis to support postpartum community care program (PCCP) as a way to decrease ED and clinic visits for PPHTN complications, and thus has a favorable economic impact on the public health care system.Study design: Retrospective cohort study using administrative databases, followed by chart review of ED visits to confirm diagnoses and estimate cost of visits and admissions. The participants were women followed by the Calgary Antenatal Community Care Program (ACCP) for hypertensive disorders, from 2014 to 2015, inclusive. The primary outcome was ED or clinic visit associated with an outpatient database record of hypertensive disorder diagnosis, within 42 days postpartum.Results: Among 319 deliveries included in the study, 30 women (9.4, 95%CI: 6.2-12.6%) visited ED or clinics for PPHTN. We identified multiple antihypertensive medication uses and abnormal postpartum gestational hypertension labs as risk factors for ED visit among these women. We estimate a CAD$152 per antenatal hypertensive patient cost benefit for PCCP.Conclusion: The proposed PCCP appears to have an economic benefit to health care system with a decrease in ED and clinic visits. Further studies with greater sample size could strengthen the findings in this study.

Management of Pregnancy with Klippel-Trenaunay-Weber Syndrome: A Case Report and Review

BACKGROUND

Klippel-Trenaunay-Weber syndrome is a rare neurocutaneous syndrome with vascular involvement. Given the rarity of the syndrome, its management in pregnancy is based on the outcome of a few case reports and expert opinion.

CASE SUMMARY

The management of a complicated case with its antepartum, intrapartum, and postpartum concerns has been addressed in this review.

CONCLUSIONS

Prenatal consults with anesthesia, general surgery, intervention radiology, and internal medicine should be arranged, prior to delivery in anticipation of all the possible complications. Apart from the pregnancy management, preconceptional counselling including the genetics, prognosis, and contraception has an important role in patient management.

A case series study of therapeutic implications of type IIIb4: a rare variant of esophageal atresia and distal tracheoesophageal fistula

BACKGROUND

A wide spectrum of variations can occur in type IIIb esophageal atresia and distal tracheoesophageal fistula [EA-TEF] (Kluth D. Atlas of esophageal atresia. J Pediatr Surg 1976; 11 (6):901-19). The aim of this study was to evaluate the variant anatomy of subtype IIIb4 EA-TEF and its therapeutic implications.

METHODS

We performed a retrospective review of 4 patients of this variant subtype within a series of 259 esophageal atresias, managed over a study period of three years, at our institution. The diagnosis was made at thoracotomy. The overlapping upper and lower esophageal pouches, initially, gave a false impression of esophageal continuity. The long TEF coursed parallel in proximity to the upper pouch (UP) and the trachea needing meticulous dissection. The TEF measured 8-10mm in diameter and was ligated and divided high on the trachea near the thoracic inlet. The patients were followed up by a contrast swallow, radioactive technetium-99m- sulfur colloid scan, echocardiography and bronchoscopy (if indicated).

RESULTS

The mean birth weight and gestational age was 2250 g and 38 weeks respectively. The mean follow up was eighteen months (range 5-42 months). An associated anorectal malformation was present in two patients while none had associated congenital heart disease. The Waterston grading was A and B in one patient each and C in two patients. All the patients had muscular UP extending up-to the level of arch of azygous vein (T(3-4)). The lower esophageal pouch (LP) and the fistula extended high, near the thoracic inlet. Tracheal injury occurred in one patient, with thin LP, warranting postoperative elective ventilation. A postoperative barium swallow did not reveal anastomotic leak or stricture in any patient. Follow-up barium swallow showed long LP extending high up in the chest, up to clavicles in all four patients and redundancy of UP in case 1. Severe gastroesophageal reflux was present in two patients. Bronchoscopy revealed tracheomalacia in case 1. Three patients were thriving well at the last follow-up. One patient died at five months of age due to aspiration pneumonia.

CONCLUSIONS

The knowledge of diagnostic and therapeutic implications of the variant subtype IIIb4 EA-TEF should be in the armamentarium of the treating surgeon to reduce pitfalls in its management.

A rare case of cardiac rhabdomyomas in a dizygotic twin pair

Cardiac rhabdomyoma (CR) is the cardiac tumour most commonly diagnosed in utero. Eighty percent of CRs are associated with tuberous sclerosis (TS). TS is a rare multi-system disease, with autosomal dominant genetic transmission. If the parents of an affected child do not have features of TS, then either one parent is mosaic for the TS gene mutation or the affected child is the result of a de novo germline mutation. We present a case of a dizygotic twin pregnancy complicated by CRs in both fetuses at 24 weeks. Twin A died in utero at 28 weeks. Preterm labour and delivery of twin B occurred at 33 weeks. Twin B had multiple small CRs and a large apical CR. At six weeks after delivery, the CRs had disappeared or reduced in size. Regression in the third trimester or postnatally is the natural course of CRs. Molecular testing for TS identified two variants in the TSC2 gene. The parents were clinically unaffected; however, the father was subsequently found on an MRI of the head to have cortical tubers, and he was found to carry the pathogenic TSC2 mutation. Since dizygotic twin pregnancy is akin to two consecutive pregnancies, the etiology in our case is due to one parent having subclinical TS. To the best of our knowledge, this is the first such case to be reported.

Pleuropulmonary blastoma with cervical lymph node metastasis at presentation

Pleuropulmonary blastoma is a rare childhood neoplasm accounting for less than one percent of all primary malignant lung tumors of children less than six years of age. Metastasis to CNS, orbit and iris, bone, contralateral lung and rarely adrenal glands, liver, kidney and pancreas has been described. This report presents a rare case of pleuropulmonary blastoma with cervical lymph node metastasis at the time of presentation.

Characterization, thermodynamic parameters and in vivo antimalarial activity of inclusion complexes of artemether

The present study aimed to improve solubility, dissolution and ultimate bioavailability of poorly soluble artemether, an antimalarial drug, by encapsulating it in β-cyclodextrin (β-CD) and its methyl and hydroxylpropyl derivatives. The effect of these complexes was confirmed by in vivo studies. Phase solubility studies indicated 1:1 stoichiometry and were supported by mass spectrometry and proton nuclear magnetic resonance ((1)H-NMR) spectroscopy. True inclusion of artemether into the cyclodextrin cavity was observed in lyophilized complexes by differential scanning calorimetry (DSC), powder X-ray diffraction (PXRD) and Fourier transform infrared spectroscopy (FT-IR) studies. The mode of inclusion was supported by two-dimensional (2D) NMR. Solution calorimetry was used to confirm 1:1 stiochiometry by determining the enthalpy of interaction between the drug and cyclodextrins. The stability constant (K) of inclusion and other thermodynamic parameters such as enthalpy (ΔH) as well as entropy (ΔS) of binding accompanying the encapsulation were determined. The calculated value of K indicated that M-β-CD has maximum complexing efficiency. Dissolution studies indicated that the highest release rate was observed for lyophilized complexes. In vivo studies of lyophilized complexes of M-β-CD showed a 3-fold increase in antimalarial activity compared to artemether and resulted in 100% eradication of parasite. However, 83% and 50% survival rates were achieved in 40 days using HP-β-CD and β-CD complexes respectively. The study concludes that encapsulation of artemether by cyclodextrins is a good alternative to enhance the bioavailability of the drug.

Kinetic studies of the degradation of an aminopenicillin antibiotic (amoxicillin trihydrate) in aqueous solution using heat conduction microcalorimetry

Recent developments in isothermal microcalorimetry allow the direct determination of kinetic and thermodynamic parameters for slow reactions from studies conducted at appropriate temperatures and under designated environmental control. The degradation kinetics of amoxicillin trihydrate has been investigated as a function of pH (1–10) and temperature (303.15–318.15 K) at 0.5 M ionic strength using heat conduction microcalorimetry. Equations were developed incorporating calorimetric accessible data, rate constants and change in enthalpy, which showed that the degradation of amoxicillin trihydrate in aqueous solution followed pseudo-first-order kinetics under our experimental conditions. The enthalpy of degradation reaction was found to be exothermic in nature. The values of the rate constant k for individual steps were determined from the values of the overall rate constants at different pH. Energy of activation of overall reaction as a function of pH and for individual rate constants was determined. The log k-pH profiles indicated specific-acid and specific-base catalysis and there were inflection points near pH 3 and pH 7 corresponding to the pKa1 and pKa2 values. Quantitatively, there was good correlation between calorimetric determined half-life (t1/2) and the literature value in the acidic region determined by other methods at 310.15 K. The presence of a β-lactam ring and of an α-amino group in the C-6 side chain played a critical role in the degradation of amoxicillin trihydrate and the zwitterionic form of the drug was found to be more stable.

Shoulder dystocia and the next delivery: Outcomes and management

OBJECTIVE

To evaluate delivery mode management decisions and the rate of shoulder dystocia recurrence for women with a prior delivery complicated by shoulder dystocia.

STUDY DESIGN

We used a computerized perinatal database and ICD-9 codes to identify all vaginal deliveries complicated by shoulder dystocia from 1996 to 2001. Subsequent deliveries over the next three years were identified and reviewed for relevant clinical, obstetric, and delivery outcomes. Management including use of labor induction, labor augmentation, operative vaginal delivery, and delivery mode (elective cesarean section (CS) vs. trial of labor (TOL)) were reviewed. The recurrence rate of shoulder dystocia was calculated and the characteristics of these cases further described.

RESULTS

Over the initial 5-year study, there were 25 995 vaginal deliveries, 205 shoulder dystocia cases (0.8%), 36 (17.5%) with neonatal injury. Of the 205 initial shoulder dystocia cases, 39 patients had 48 subsequent deliveries at our institution (a subsequent delivery rate of 23% at our institution, significantly less than the overall population (42%, p < 0.001)). Complete data were available for 47 deliveries. Four women had elective CS without labor (one due to prior shoulder dystocia), 43 (91.5%) had a TOL, and 42 (88%) achieved vaginal delivery. Recurrent shoulder dystocia complicated 9.5% (4/42) of deliveries; one case included neonatal brachial plexus injury that resolved prior to hospital discharge. Of the four recurrent shoulder dystocia cases, none were complicated by maternal diabetes, macrosomia, prolonged second stage of labor, or underwent an operative vaginal delivery. No statistically significant univariate differences were seen between the recurrence group and the no-shoulder dystocia vaginal delivery group; however birth weight and nulliparity at initial shoulder dystocia pregnancy jointly demonstrated a relationship of recurrence (p = 0.048).

CONCLUSION

In TOL cases that result in a vaginal delivery, the rate of recurrence of shoulder dystocia is high--approximately 10 times higher than the rate for the general population. Often the only identifiable risk factor is the prior history itself, which may influence delivery management in subsequent pregnancies. Birth weight and nulliparity at initial shoulder dystocia pregnancy may influence clinical decision-making in cases of prior shoulder dystocia.

Overestimation of fetal weight by ultrasound: does it influence the likelihood of cesarean delivery for labor arrest?

OBJECTIVE

We sought to determine whether the overestimation of ultrasound-derived estimated fetal weight (EFW) is associated with increased diagnosis of labor arrest.

STUDY DESIGN

This is a historical cohort study of nulliparous women with term pregnancies who underwent bedside ultrasound examination for EFW before labor induction. Labor outcomes of women with EFW overestimation > 15% the actual birthweight were compared with those with EFW not overestimated.

RESULTS

Overestimation of EFW occurred in 9.5% of cases (23/241). The rate of cesarean delivery (CD) for labor arrest was higher for those with EFW overestimation (34.8% vs 13.3%; P = .01) even though there were no differences in length of the induction duration. After adjusting for confounding factors, EFW overestimation remained associated with CD for labor arrest (odds ratio, 4.8; 95% confidence interval, 1.5-15.2).

CONCLUSION

Our finding suggests that an overestimation of EFW may be associated with a lower threshold for CD for labor arrest.

Biophysical profile in the treatment of intrauterine growth-restricted fetuses who weigh <1000 g

OBJECTIVE

The aim of this study was to determine the biophysical profile (BPP) usefulness in the prediction of cord pH, base excess, and guidance regarding the timing of delivery in preterm intrauterine growth-restricted (IUGR) fetuses.

STUDY DESIGN

A BPP was performed daily in 48 IUGR fetuses and was considered abnormal when it was 2/10 on 1 single occasion or 4/10 on 2 consecutive occasions 2 hours apart.

RESULTS

The median gestational age and fetal weight for the total population was 27.6 weeks and 632 g, respectively. In 13 fetuses with a BPP of 6, there were 3 deaths, and 7 fetuses were acidemic. In 27 fetuses with a BPP of 8, there were 3 deaths, and 12 fetuses were acidemic.

CONCLUSION

BPP alone is not a reliable test in the treatment of preterm IUGR fetuses, because of high false-positive and -negative results. The common notion of a good BPP providing reassurance for at least 24 hours is not applicable in severely preterm IUGR fetuses who weigh <1000 g.

Duration of labor induction in nulliparous women at term: how long is long enough?

We evaluated the relationship between duration of labor induction and successful vaginal delivery (VD) in nulliparous women at term. Nulliparous women with singleton pregnancies > or = 37 weeks who underwent labor induction at a single institution were studied. Exclusion criteria were nonvertex presentation, stillbirth, fetal chromosomal/structural abnormalities, spontaneous labor, and spontaneous rupture of membranes. VD rates and maternal/neonatal outcomes were evaluated and compared with respect to the duration from induction to delivery. Over the 1-year study period, 340 women met all criteria. Seventy-five percent achieved VD (n = 255), 40.6% of whom had rate of cervical dilation in active labor < 1.0 cm/hour. Women requiring cesarean delivery were more likely to have fetal acidemia, admission to the neonatal intensive care unit, chorioamnionitis, and endometritis. There was no association with prolonged induction to delivery intervals and adverse maternal/neonatal outcomes. In our population, only 5.7% of nulliparous women undergoing labor induction at term remain undelivered at 48 hours. Of women achieving VD, > 40% had rate of cervical dilation in active labor < 1.0 cm/hour.

Prospective study of a 10-gene molecular assay to predict tissue of origin in patients with carcinoma of unknown primary (CUP)

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Background: Carcinoma of unknown primary (CUP) where metastatic disease presents without an identifiable primary represents ∼ 3–5% of all cancers. Identifying the origin of the primary tumor in CUP pts can facilitate rational choice of therapeutic regimens. Veridex developed an optimized set of 10 gene markers for a quantitative reverse transcriptase polymerase chain reaction (qRTPCR) assay, and demonstrated high accuracy in predicting the tissue of origin with formalin-fixed, paraffin-embedded (FFPE) metastatic carcinoma samples (J Mol Diagn 2006, 8: 320–9). In this study, the 10-gene assay was prospectively evaluated in CUP pts. Methods: We collected FFPE biopsy tissue specimens from consenting CUP pts at MD Anderson. Eligibile pts met our definition for CUP with adenocarcinoma or poorly differentiated carcinoma. Samples were obtained prior to treatment. 51 pts have been enrolled so far and 11 were ineligible [insufficient samples].Of the 40 pts, qRTPCR assay has been performed on 33 pts. Data on 27/33 is available. A statistical model was used to determine the probability that the metastatic carcinoma tissue assayed originated from 1 of the following 7 categories: lung, pancreas, colon, breast, prostate, ovarian, and other. Subsequently, prediction of the primary by qRTPCR was independently compared with metastatic pattern spread, tumor pathological features, and results of clinical and pathology diagnostic workups. Results: Assay results on 27 prospectively collected CUP patient biopsy specimens are available. In total, CUP tissue of origin prediction by the assay correlated with clinical and pathological assessment in 21 out of 27 evaluated pts (78 %). The most common cancer type predicted by the assay was colon cancer, which correlated with predominantly intra-abdominal metastatic spread in this pt cohort. Conclusions: This prospective study demonstrated the feasibility of conducting gene analysis to predict metastatic carcinoma tissue of origin in FFPE tissue specimens derived from CUP patients. Overall distribution of various primary cancer types as predicted by the assay was consistent with the historical distribution reported for CUP. Assay prediction was concordant with clinical and pathological assessment in 78 % CUP pts.

No significant financial relationships to disclose.

The combination of bevacizumab (B) and erlotinib (E) shows significant biological activity in patients with advanced hepatocellular carcinoma (HCC)

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Purpose: HCC is the 5th most common solid tumor worldwide and the incidence is rising in western countries. >75% of patients (pts) have advanced disease and are ineligible for surgical or loco-regional therapies. Existing cytotoxic chemotherapy does not prolong pt survival and can have significant toxicity in cirrhotic pts. HCC are highly vascular tumors, and based on the prevalence of vascular endothelial growth factor (VEGF) and epidermal growth factor receptors (EGFR) in HCC, we are conducting a phase II, single-arm, open-label trial of B and E in pts with HCC. Patients and Methods: Eligibility criteria include biopsy-proven unresectable HCC, Child- Pugh class A or B cirrhosis, bilirubin = 2.0 mg/dL, transaminases (TA)= 5 x ULN, Plts = 50,000 K/UL and ECOG PS = 2. Prior allowed therapies are surgery, external radiotherapy, ablation, chemoembolization (TACE) and one systemic therapy. Pts receive B 10 mg/kg q14 days plus E 150 mg orally daily until PD or unacceptable toxicity. Results: The primary endpoint is the percent of pts alive and progression free (PFS) after 16 wks of therapy based on median PFS of 3–5 mos in published studies. Response is evaluated by RECIST. 29 pts have been enrolled. For all pts, the med. age was 61 (29–77), 24 (82.8%) were male, 19 (65.5%) were Caucasian; ECOG PS 0, 11 pts, PS 1, 18 pts; 6 had prior systemic therapy, and 10 pts had prior TACE. Of the 27 pts evaluable for response, 1 pt confirmed CR, 5 pts PRs (4 confirmed) (22% RR; 5/6 pts 1st line) 9 pts SD at 16 wks (55% PFS 16 wks); 5 additional pts SD at 8 wks (74% disease control rate). 2 pts PD at 16 wks, 1 pt PD at 8 wks, 2 removed for toxicity (proteinuria, fatigue); 1 early death. 12/14 pts with SD as their best response showed minor tumor shrinkage, decreased tumor vascularity or increased necrosis. Generally B+E are well tolerated; Gr 3–4 toxicities were TA elevation, hyperkalemia, acne (1 pt each), diarrhea, proteinuria (2 pts), GI bleed (3 pts), fatigue (4 pts), hypertension (5 pts). Conclusions: Based on these early encouraging results and favorable toxicity profile, the combination of B + E appears to have significant clinically meaningful biologic activity in HCC. The trial will continue to full accrual of 40 patients. The combination of B + E warrants further study in HCC.

No significant financial relationships to disclose.

Phase I study to determine the safety and pharmacokinetics of 4-hour intravenous infusion of TAS-106 on a once per week for 3 consecutive weeks every 28-day schedule in patients with solid tumors

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Background: Most solid tumors are slow growing so the S-phase-specific anti-tumor drugs have limited efficacy. The antitumor nucleoside 3’-C-ethynylcytidine (ECyd, TAS-106) inhibits RNA synthesis by blocking RNA polymerases. In vitro, TAS-106 has demonstrated cytotoxicity 300 times greater than that of 5-FU against human lung, colorectal, gastric, pancreas and breast cancer cells. This trial was based on a previous clinical trial, in which study drug was administered as a bolus injection wkly for 3 consecutive weeks every 28- days and TAS-106 caused reversible dose-limiting peripheral neuropathy, and the safety dose was 1.32 mg/m2/dose. Methods: Objectives of this study were to determine the recommended phase II dose (RP2D) and the dose-limiting toxicity of TAS-106 administered by 4-hour IV infusion wkly for 3 consecutive weeks every 28-days; to investigate the clinical pharmacokinetics and pharmacodynamics of TAS-106, and document any antitumor activity observed. Results: A total of 18 patients (pts) were treated in the study; 16 pts were evaluable. The med age was 59; 11 female. A total of 44 courses of therapy were initiated by pts during the study; 39 courses (88.6%) were completed. Six pts had best tumor responses of stable disease (SD) and 9 pts had best tumor responses of progressive disease (PD); no pts had a complete or partial response. The mean duration of SD was 103.7 days. Median time to treatment failure was 57.0 days. At the RP2D (2.04 mg/m2/dose), 2 of 8 pts had best tumor response of SD with a mean duration of 132.0 days and three of the 8 pts had PD. For 12 pts (66.7%), adverse events (AEs) were considered to be related to TAS-106; the most commonly reported drug-related AEs were tremor (8 pts, 44.4%), neuropathy (4 pts, 22.2%), and peripheral neuropathy and fatigue (3 pts, 16.7% each) . No Grade 4 drug-related AEs were reported. Plasma concentrations increased with increasing dose, and at 2.04 mg/m2, the Cmax was 47.6±1.3 ng/mL. Conclusions: The safety profile of TAS-106 administered via wkly 4-hour IV infusion appears to be similar to the toxicity profile of TAS-106 when administered as a wkly bolus. In wkly 4-hour IV infusion, peripheral neuropathy was acceptable at the RP2D.

No significant financial relationships to disclose.

Quantitative analysis of in vitro compatibility of binary and ternary mixtures of nitroimidazole and macrolides in combination with omeprazole using a calorimetric technique

In the present study, in vitro interactions between nitroimidazoles, macrolides and omeprazole in binary and ternary mixtures were examined by measuring their enthalpy of solution (delta(sol)H) using a calorimetric technique. A comparison of the enthalpy of solution of the pure drugs with those of binary and ternary mixtures at pH 2 and 6 was made to indicate the magnitude of interaction between them. The delta(sol)H for all the nitroimidazoles is endothermic at pH 2 and 6 but both the macrolides show exothermic behavior, whereas the enthalpy of solution of omeprazole changes from -40.52 to 4.35 kJmol(-1) as the pH changes from 2 to 6. The results have been quantified by determining the excess enthalpy of solution for both binary and ternary systems. The small deviations from ideality for all the binary systems are attributed to various non-bonding interactions between different functional groups on both the drug molecules. The results suggest compatibility of drug pairs in their binary mixtures. However, ternary mixtures show somewhat larger interactions. The magnitude of interaction enthalpy of a ternary mixture comprising tinidazole, clarithromycin and omeprazoles which are available as a marketed kitshas been calculated to be significant, suggesting that the three drugs cannot be co-formulated.

The histopathology of congenital pouch colon associated with anorectal agenesis

The colonic pouch excised during surgery in 17 patients with congenital pouch colon associated with anorectal agenesis (CPC) was subjected to detailed histological examination after staining with hematoxylin and eosin. The patients included 11 newborns, 3 infants, and 3 older children. The most frequently observed abnormalities were acute and chronic inflammation of the mucosa and submucosa, focal or generalized thinning of muscle layers, especially of the outer muscle coat, disorganized muscle layers, a decreased number of mature ganglion cells, and neuronal hyperplasia and hypertrophy in nerve plexuses. Ectopic heteroplastic tissues were identified in 2 patients. These findings suggest that the colonic pouch in CPC represents abnormally developed colonic tissue and points to the similarity with segmental dilatation of the colon. The neuromuscular abnormalities explain the physiological characteristics of the colonic pouch, namely weak peristalsis as well as the propensity to undergo marked dilatation even after tubularization.

Microcalorimetric evaluation of the in vitro compatibility of amoxicillin/clavulanic acid and ampicillin/sulbactam with ciprofloxacin

Solution calorimetric technique has been used to determine the compatibility of binary and ternary systems of ampicillin trihydrate (AMP), sulbactam sodium (SS), amoxicillin trihydrate (AM), potassium clavulanate (PC) and ciprofloxacin hydrochloride (CP). The enthalpy of solution (DeltasolH) were obtained over a wide range of composition in the pH range 2-9. For all the pure drugs the DeltasolH is endothermic in nature. The molar enthalpies of interaction of binary (DeltaHbi.E) and ternary (DeltaHter.E) mixtures of the drugs in aqueous buffers have been determined. The DeltaHbi.E for all binary systems is negative and pH dependent (maximum pH 6-8) indicating the interaction among charged species of the drugs. In case of binary systems with CP the magnitude of DeltaHbi.E indicate strong interactions. The variation and magnitude of DeltaHbi.E for the systems is discussed in terms of hydrogen bonding and van der Waal's interaction in the solution. The interaction parameter for ternary systems (A) is positive indicating repulsive interaction among the drugs. The coefficients hi's calculated from Redlich-Kister equation for binary systems (DeltaHbi.E) and ternary interaction parameter (A) were used to predict the compatibility of the marketed formulations in pH range studied.

Kinetics of degradation of diclofenac sodium in aqueous solution determined by a calorimetric method

An isothermal heat conduction microcalorimeter has been used to study the stability of diclofenac sodium both alone and its inclusion complex with beta-cyclodextrin in aqueous solution. The rates of heat evolved during degradation of diclofenac sodium have been measured by a highly sensitive microcalorimetric technique as function of concentration, pH and temperature. The calorimetric accessible data have been incorporated in the equations for determination of rate constants, change in enthalpy and order of reaction. The decomposition of diclofenac sodium both alone and its inclusion complex with beta-cyclodextrin in solution corresponds to a pseudo-first order reaction. The values of rate constants, k's at 338.15 K, (calculated from the variation of heat evolution with the time) for the degradation of diclofenac sodium at pH 5, 6, 7, 8 and its inclusion complex with beta-cyclodextrin at pH 7 are found to be 4.71 x 10(-4), 5.69 x 10(-4), 6.12 x 10(-)4, 6.57 x 10(-4) and 4.26 x 10(-4) h(-1) respectively. There is good agreement between calorimetric determined t(0.5) and literature values. It has been found that beta-cyclodextrin retards the degradation of diclofenac sodium. The kinetic parameters have been calculated for the reaction. The negative entropy of activation suggests the formation of an ordered transition state.

Microcalorimetric studies to determine the enthalpy of solution of diclofenac sodium, paracetamol and their binary mixtures at 310.15 K

A sensitive and selective microcalorimetric technique has been used to determine the enthalpy of solution of diclofenac sodium (DS), paracetamol (PC) and their binary mixtures over a wide range of composition in the pH range 4-12. The systems showed endothermic behavior. The molar enthalpies of solutions of DS vary between 42.26+/-0.16 and 50.48+/-0.03 kJ mol(-1) at pH 4-9 and for PC from 24.28+/-0.05 to 36.03+/-0.01 kJ mol(-1) at pH 5-12. The excess molar enthalpy of their mixtures has also been determined. The values of excess molar enthalpy of solutions are negative and very low in magnitude indicating no specific interaction between DS and PC in solution.

Calorimetric studies of diclofenac sodium in aqueous solution of cyclodextrin and water-ethanol mixtures

The technique of solution calorimetry has been employed to study the interaction between diclofenac sodium and beta-cyclodextrin by determining the enthalpies of solution of the drug in water and in aqueous beta-cyclodextrin solution. Thermodynamic parameters characterizing the binding process such as enthalpy deltaH0, equilibrium constant K, free energy deltaG0 and entropy deltaS0 have been calculated to be 12.00 kJ mol(-1), 1670 dm3 mol(-1), -19.03kJ mol(-1) and 22.98 J K(-1) mol(-1), respectively. Enthalpies of solution of diclofenac sodium have also been determined in water-ethanol mixtures.

Congenital pouch colon associated with segmental dilatation of the colon

A 1-day-old boy who presented with an anorectal malformation (ARM) was found to have a segmental dilatation of the colon (SDC) associated with a typical congenital pouch colon (CPC) malformation. The distal colonic pouch terminated in a high colovesical fistula. The posterior portion of the perineal raphé was duplicated and ended in 2 anal dimples. Both dilated segments of the colon were excised. The similarity between CPC and SDC is highlighted, and the possible embryogenesis of both conditions is discussed.

Two cases of pseudoduplication of the external genitalia

In two newborn boys an accessory rudimentary phallus and scrotal sacs were present on the surface of a midline perineal swelling. Both boys had an associated high anorectal anomaly (ARA), a small phallus, and a bifid scrotum with absence of the scrotal raphé. One also had penile torsion with hypospadias and an accessory anal dimple. During definitive surgery for the ARA in one patient, excision of the perineal soft-tissue mass and overlying duplicated penoscrotal tissue was performed. The embryogenesis of this condition is discussed.

Complete diphallia associated with features of covered exstrophy

This report describes a 1-day-old boy with complete true diphallia associated with features of covered or pseudo-exstrophy and an anorectal malformation. The urinary bladder and rectum were single. A divided sigmoid colostomy was constructed at birth for the anorectal anomaly. Complete diphallia and its likely embryogenesis are discussed.

Female pseudohermaphroditism associated with cloacal anomalies: faulty differentiation in the caudal developmental field

A 1(1/2)-year-old girl with a urogenital sinus defect associated with an enlarged phalluslike clitoris is described. The child had an anteriorly located anus, a single kidney with grade III vesicoureteric reflux, a 3.5-cm-long common urethrovaginal channel, a large vesical calculus, and a hamartoma in the pubic region. After a preliminary colostomy, definitive surgery consisted of urethral reconstruction, vaginal reconstruction using a colonic graft, and posterior relocation of the anus. The discussion centers on a review of the previously reported cases of female pseudohermaphroditism associated with cloacal or urogenital sinus defects (FPHCD). The likely embryogenesis of this condition is discussed, and the similarity of the features with those seen in some patients with complete penoscrotal transposition (CPST) is highlighted.