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Doughty ES, Verilhac KN, McLaren S, Post MD. The importance of fetal autopsy: An institutional review and development of best practices for reporting size and estimating gestational age at demise. Am J Clin Pathol 2024; 161:283-288. [PMID: 37921079 DOI: 10.1093/ajcp/aqad147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 09/27/2023] [Indexed: 11/04/2023] Open
Abstract
OBJECTIVES Fetal and neonatal autopsy offers critical insight into disease processes and clinical decision-making in reproductive medicine. Elucidating the cause of death and gaining a deeper understanding of the entities leading to fetal demise aids in anticipatory guidance for physicians and patients. Accurate assessment of growth and dating of fetuses is an important aspect of classifying pathology in the fetal and neonatal population. This study aims to optimize the autopsy approach to sizing and dating discrepancies, in addition to exploring the current trends in causes of stillbirth, with respect to placental, fetal/neonatal, and maternal factors, and rates of cases that remain undetermined after autopsy. METHODS A single-institution retrospective review of autopsy reports from mid-2008 through 2021 revealed 243 complete perinatal autopsy examinations. RESULTS Placental cause of demise was identified in 46% of cases. Cause of demise was undetermined in 22% of cases. Evaluation of a subset of cases exposed minimal to no reporting of size and/or dating discrepancies in almost half of cases with undetermined cause of death. CONCLUSIONS "Best practice" suggestions for sizing and dating fetuses/neonates in the postmortem period have been developed to aid in delivering clear, consistent reports. Because fetal and neonatal autopsy is an invaluable tool for understanding the factors that contribute to stillbirth, it is important to use appropriate sizing and dating methods and consistent language to deliver proper patient education and clinical guidance.
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Affiliation(s)
- Elizabeth S Doughty
- Department of Pathology, University of Colorado Anschutz Medical Campus, Aurora, CO, US
| | | | | | - Miriam D Post
- Department of Pathology, University of Colorado Anschutz Medical Campus, Aurora, CO, US
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Doughty ES, Post MD. Fetal and Neonatal Autopsy in the Molecular Age: Exploring Tissue Selection for Testing Success. Pediatr Dev Pathol 2024; 27:148-155. [PMID: 38098260 DOI: 10.1177/10935266231214880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/13/2024]
Abstract
While conventional autopsy is the gold-standard for determining cause of demise in the fetal and neonatal population, molecular analysis is increasingly used as an ancillary tool. Testing methods and tissue selection should be optimized to provide informative genetic results. This institutional review compares testing modalities and postmortem tissue type in 53 demises occurring between 20 weeks of gestation and 28 days of life. Testing success, defined as completion of analysis, varies by technique and may require viable cells for culture or extractable nucleic acid. Success was achieved by microarray in 29/30 tests (96.7%), karyotype in 40/54 tests (74.1%), fluorescent in situ hybridization in 5/9 tests (55.6%), and focused gene panels in 2/2 tests (100%). With respect to tissue type, postmortem prepartum amniotic fluid was analyzed to completion in 100% of tests performed; compared to 84.0%, 54.5%, and 80.8% of tests using placenta, fetal only, and mixed fetal-placental tissue collection, respectively. Sampling skin (83.3%, in cases with minimal maceration) and kidney (75.0%) were often successful, compared to lower efficacy of umbilical cord (57.1%) and liver (25.0%). Addition of genetic testing into cases with anomalous clinical and gross findings can increase the utility of the final report for family counseling and future pregnancy planning.
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Affiliation(s)
- Elizabeth S Doughty
- Department of Pathology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Miriam D Post
- Department of Pathology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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White A, Pruszynski J, Williams R, Duryea EL. Transfusion and hematologic indices in cases of stillbirth due to placental abruption. Am J Obstet Gynecol 2023; 229:677.e1-677.e10. [PMID: 37364802 DOI: 10.1016/j.ajog.2023.06.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 06/17/2023] [Accepted: 06/21/2023] [Indexed: 06/28/2023]
Abstract
BACKGROUND Stillbirth because of placental abruption is often associated with maternal hemorrhage and coagulopathy. OBJECTIVE This study aimed to describe blood product requirements, hematologic indices, and the overall clinical picture of patients experiencing abruption demise. STUDY DESIGN This retrospective cohort included patients with abruption demise at an urban hospital from 2010 to 2020. Outcome data from patients who delivered stillborn infants ≥500 g or with gestational age of ≥24 weeks were included. Abruption was a clinical diagnosis made by a multidisciplinary stillbirth review committee. The overall number and type of blood products given were analyzed. Patients with a stillbirth who required blood transfusion were compared with those that did not. In addition, the hematologic indices of these 2 populations were analyzed and compared with one another. Finally, the overall clinical characteristics of the 2 populations were analyzed. The analysis of data included chi-square, t test, and logistic and negative binomial regression models. RESULTS Of 128,252 deliveries, 615 patients (0.48%) experienced a stillbirth, with 76 cases (12%) caused by abruption. Of note, 42 patients (55.2%) required blood transfusion; all received either packed red blood cells or whole blood with a median 3.5 units (2.0-5.5) received. The total units ranged from 1 to 59, with 12 of 42 patients (29%) requiring ≥10 units. Maternal age, gestational age, and mode of delivery were not different, with most (61/76 [80%]) delivering vaginally. Hematocrit level on arrival (odds ratio, 0.80; 95% confidence interval, 0.68-0.91; P=.002) and vaginal bleeding on arrival (odds ratio, 3.73; 95% confidence interval, 1.15-13.40; P=.033) were associated with blood transfusion, as was a diagnosis of preeclampsia (odds ratio, 8.40; 95% confidence interval, 2.49-33.41; P=.001). Those that required a blood transfusion often presented with lower hematologic indices and were more likely to develop disseminated intravascular coagulation (28% vs 0%; P<.001). CONCLUSION Most patients experiencing stillbirth because of abruption required blood transfusion, with almost 1 in 3 of those patients consuming ≥10 units of blood products. Hematocrit level on arrival, vaginal bleeding, and preeclampsia were all predictors of the need for blood transfusion. Those requiring blood transfusion were more likely to develop disseminated intravascular coagulation. Blood transfusion should be prioritized when abruption demise is suspected.
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Affiliation(s)
- Alesha White
- Department of Obstetrics and Gynecology, The University of Texas Southwestern Medical Center, Parkland Health System, Dallas, TX.
| | - Jessica Pruszynski
- Department of Obstetrics and Gynecology, The University of Texas Southwestern Medical Center, Parkland Health System, Dallas, TX
| | - Rachel Williams
- Department of Obstetrics and Gynecology, The University of Texas Southwestern Medical Center, Parkland Health System, Dallas, TX
| | - Elaine L Duryea
- Department of Obstetrics and Gynecology, The University of Texas Southwestern Medical Center, Parkland Health System, Dallas, TX
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Kontopoulos E, Quintero RA. Fetoscopic demonstration of feto-fetal hemorrhage before actual demise of a monochorionic twin, successful antenatal treatment, and narrative review of the literature. J Matern Fetal Neonatal Med 2023; 36:2215898. [PMID: 37290961 DOI: 10.1080/14767058.2023.2215898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 05/10/2023] [Accepted: 05/15/2023] [Indexed: 06/10/2023]
Abstract
Feto-fetal hemorrhage (FFH) through placental vascular anastomoses is believed to be responsible for the death or damage of a "second twin" after the demise of a "first twin (co-twin)" in monochorionic twin pregnancies. However, the timing of FFH has been difficult to determine. The resulting anemia in the surviving twin can be suspected by the finding of an elevated middle cerebral artery peak-systolic velocity (MCA-PSV), but this elevation may lag for at least 4 h after the demise of the first twin. Knowledge of the timing of FFH may have important clinical implications, as it may dictate if and when attempts to prevent death or damage to the second twin by delivery or intrauterine fetal transfusion would be warranted. We present a case that supports the notion that FFH occurs before the actual demise of the first twin. A review of the literature was also conducted.
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Affiliation(s)
- Eftichia Kontopoulos
- The USFetus Research Consortium, Miami, FL, USA
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Florida International University, Herbert Wertheim School of Medicine, Miami, FL, USA
- The Fetal Institute, Miami, FL, USA
| | - Ruben A Quintero
- The USFetus Research Consortium, Miami, FL, USA
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Florida International University, Herbert Wertheim School of Medicine, Miami, FL, USA
- The Fetal Institute, Miami, FL, USA
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Yusuf H, Stokes J, Wattar BHA, Petrie A, Whitten SM, Siassakos D. Chance of healthy versus adverse outcome in subsequent pregnancy after previous loss beyond 16 weeks: data from a specialized follow-up clinic. J Matern Fetal Neonatal Med 2023; 36:2165062. [PMID: 36632655 DOI: 10.1080/14767058.2023.2165062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
PURPOSE Women with a previous fetal demise have a 2-20 fold increased risk of another stillbirth in a subsequent pregnancy when compared to those who have had a live birth. Despite this, there is limited research regarding the management and outcomes of subsequent pregnancies. This study was conducted to accurately quantify the chances of a woman having a healthy subsequent pregnancy after a pregnancy loss. METHODS A retrospective study was conducted at a tertiary-level unit between March 2019 and April 2021. We collected data on all women with a history of previous fetal demise attending a specialized perinatal history clinic and compared the risk of subsequent stillbirth to those with a normal pregnancy outcome. Outcome data included birth outcome, obstetric and medical complications, gestational age and birth weight and mode of delivery. Those who had healthy subsequent pregnancies were compared with those who experienced adverse outcomes. RESULTS A total of 101 cases were reviewed. Ninety-six women with subsequent pregnancies after a history of fetal demise from 16 weeks were included. Seventy-nine percent of women (n = 76) delivered a baby at term, without complications. Overall, 2.1% had repeat pregnancy losses (n = 2) and 2.1% delivered babies with fetal growth restriction (n = 2). There were no cases of abruption in a subsequent pregnancy. Eighteen neonates were delivered prematurely (18.4%), 15 of these (83.3%) were due to iatrogenic causes and three (16.7%) were spontaneous. In univariable logistic regression analyses, those with adverse outcomes in subsequent pregnancies had greater odds of pre-eclampsia (Odds ratio *(OR) = 3.89, 95% CI = 1.05-14.43, p = .042) and fetal growth restriction (OR = 4.58, 95% CI = 1.41-14.82, p = 0.011) in previous pregnancies compared to those with healthy outcomes. However, in multivariable logistic regression analyses, neither variable had a significant odds ratio (OR = 2.03, 95% CI = 0.44-9.39, p = .366 and OR = 3.42, 95% CI = 0.90 - 13.09, p = .072 for pre-eclampsia and FGR, respectively). CONCLUSION Four in five women had a healthy subsequent pregnancy. This is a reassuring figure for women when contemplating another pregnancy, particularly if cared for in a specialist clinic.
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Affiliation(s)
- Hannah Yusuf
- Institute for Women's Health, University College London, London, United Kingdom of Great Britain and Northern Ireland.,UCL Medical School, University College London, London, United Kingdom of Great Britain and Northern Ireland
| | - Jenny Stokes
- Division of Women's Health, University College London Hospitals NHS Foundation Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Bassel H Al Wattar
- Institute for Women's Health, University College London, London, United Kingdom of Great Britain and Northern Ireland.,Reproductive Medicine Unit, University College London Hospital, London, United Kingdom of Great Britain and Northern Ireland
| | - Aviva Petrie
- UCL Eastman Dental Institute, University College, London, United Kingdom of Great Britain and Northern Ireland
| | - Sara M Whitten
- Institute for Women's Health, University College London, London, United Kingdom of Great Britain and Northern Ireland.,Division of Women's Health, University College London Hospitals NHS Foundation Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Dimitrios Siassakos
- Institute for Women's Health, University College London, London, United Kingdom of Great Britain and Northern Ireland.,Division of Women's Health, University College London Hospitals NHS Foundation Trust, London, United Kingdom of Great Britain and Northern Ireland.,Wellcome EPSRC Centre for Interventional & Surgical Sciences (WEISS), London, United Kingdom of Great Britain and Northern Ireland.,NIHR Biomedical Research Centre, University College London Hospital, London, United Kingdom of Great Britain and Northern Ireland
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DuBose B, Tembunde Y, Goodman KE, Pineles L, Nadimpalli G, Baghdadi JD, Parchem JG, Harris AD, Pineles BL. Delivery outcomes in a cohort of pregnant patients with COVID-19 with and without viral pneumonia. Am J Obstet Gynecol MFM 2023; 5:101077. [PMID: 37399892 PMCID: PMC11018246 DOI: 10.1016/j.ajogmf.2023.101077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 06/18/2023] [Accepted: 06/29/2023] [Indexed: 07/05/2023]
Abstract
BACKGROUND Among pregnant people, COVID-19 can lead to adverse outcomes, but the specific pregnancy outcomes that are affected by the disease are unclear. In addition, the effect of the severity of COVID-19 on pregnancy outcomes has not been clearly identified. OBJECTIVE This study aimed to evaluate the associations between COVID-19 with and without viral pneumonia and cesarean delivery, preterm delivery, preeclampsia, and stillbirth. STUDY DESIGN We conducted a retrospective cohort study (April 2020-May 2021) of deliveries between 20 and 42 weeks of gestation from US hospitals in the Premier Healthcare Database. The primary outcomes were cesarean delivery, preterm delivery, preeclampsia, and stillbirth. We used a viral pneumonia diagnosis (International Classification of Diseases -Tenth-Clinical Modification codes J12.8 and J12.9) to categorize patients by severity of COVID-19. Pregnancies were categorized into 3 groups: NOCOVID (no COVID-19), COVID (COVID-19 without viral pneumonia), and PNA (COVID-19 with viral pneumonia). Groups were balanced for risk factors by propensity-score matching. RESULTS A total of 814,649 deliveries from 853 US hospitals were included (NOCOVID: n=799,132; COVID: n=14,744; PNA: n=773). After propensity-score matching, the risks of cesarean delivery and preeclampsia were similar in the COVID group compared with the NOCOVID group (matched risk ratio, 0.97; 95% confidence interval, 0.94-1.00; and matched risk ratio, 1.02; 95% confidence interval, 0.96-1.07; respectively). The risks of preterm delivery and stillbirth were greater in the COVID group than in the NOCOVID group (matched risk ratio, 1.11; 95% confidence interval, 1.05-1.19; and matched risk ratio, 1.30; 95% confidence interval, 1.01-1.66; respectively). The risks of cesarean delivery, preeclampsia, and preterm delivery were higher in the PNA group than in the COVID group (matched risk ratio, 1.76; 95% confidence interval, 1.53-2.03; matched risk ratio, 1.37; 95% confidence interval, 1.08-1.74; and matched risk ratio, 3.33; 95% confidence interval, 2.56-4.33; respectively). The risk of stillbirth was similar in the PNA and COVID group (matched risk ratio, 1.17; 95% confidence interval, 0.40-3.44). CONCLUSION Within a large national cohort of hospitalized pregnant people, we found that the risk of some adverse delivery outcomes was elevated in people with COVID-19 with and without viral pneumonia, with much higher risks in the group with viral pneumonia.
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Affiliation(s)
- Brianna DuBose
- University of Maryland School of Medicine, Baltimore, MD (Mses DuBose and Tembunde)
| | - Yazmeen Tembunde
- University of Maryland School of Medicine, Baltimore, MD (Mses DuBose and Tembunde)
| | - Katherine E Goodman
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD (Dr Goodman, Ms L Pineles, and Drs Nadimpalli, Baghdadi, and Harris)
| | - Lisa Pineles
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD (Dr Goodman, Ms L Pineles, and Drs Nadimpalli, Baghdadi, and Harris)
| | - Gita Nadimpalli
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD (Dr Goodman, Ms L Pineles, and Drs Nadimpalli, Baghdadi, and Harris)
| | - Jonathan D Baghdadi
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD (Dr Goodman, Ms L Pineles, and Drs Nadimpalli, Baghdadi, and Harris)
| | - Jacqueline G Parchem
- Department of Obstetrics, Gynecology and Reproductive Sciences, John P. and Kathrine G. McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX (Dr Parchem)
| | - Anthony D Harris
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD (Dr Goodman, Ms L Pineles, and Drs Nadimpalli, Baghdadi, and Harris)
| | - Beth L Pineles
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA (Dr B Pineles).
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Corn M, Pham T, Kemp W. Adverse Fetal Outcomes and Histopathology of Placentas Affected by COVID-19: A Report of Four Cases. Cureus 2023; 15:e44402. [PMID: 37664389 PMCID: PMC10468721 DOI: 10.7759/cureus.44402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2023] [Indexed: 09/05/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19) has had significant impacts on mothers and neonates. In this report, we present four unique cases of COVID-19 infections in pregnancy and its effects on the mother, fetus, and placenta. Four mothers presented to the hospital during their pregnancy. Each had tested COVID-19-positive 1-29 days prior to admission. Gestational age ranged from 16 weeks six days to 36 weeks six days. Three of the four cases resulted in fetal demise or infant expiration. The common finding among all four cases was pathologic changes in the placenta. Most of the placentas were small for gestational age and had extensive villous infarction. There was also histiocytic intervillositis with villous necrosis and perivillous fibrin deposition. The placentas demonstrated positive staining of syncytiotrophoblasts for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spike S1 subunit protein. SARS-CoV-2 RNA was detected in tissue samples of two of the fetuses demonstrating vertical transmission. A higher incidence of severe COVID-19 disease course has been observed in pregnant women. Prior to the SARS-CoV-2 pandemic, chorionic histiocytic intervillositis of the placenta was rarely seen, and mostly of unknown etiology. The increase in placental fibrin levels results in decreased maternal placenta blood flow ensuing hypoxic stress in the fetus. Intrauterine hypoxia has been associated with alterations in brain structure and function resulting in defects in motor skills, cerebral palsy, decreased brain weight, schizophrenia, and other forms of cognitive impairment.
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Affiliation(s)
- Megan Corn
- Obstetrics and Gynaecology, University of North Dakota School of Medicine and Health Sciences, Grand Forks, USA
| | - Truc Pham
- Pathology, Incyte Pathology, Spokane Valley, USA
| | - Walter Kemp
- Pathology, State of Montana, Forensic Science Division, Billings, USA
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Snoep MC, Bet BB, Zwanenburg F, Knobbe I, Linskens IH, Pajkrt E, Rozendaal L, Van der Meeren LE, Clur SA, Haak MC. Factors related to fetal demise in cases with congenital heart defects. Am J Obstet Gynecol MFM 2023; 5:101023. [PMID: 37220848 DOI: 10.1016/j.ajogmf.2023.101023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 05/04/2023] [Accepted: 05/15/2023] [Indexed: 05/25/2023]
Abstract
BACKGROUND Congenital heart defects are the most common congenital anomaly. Despite the increasing survival of these children, there is still an increased incidence of fetal demise, frequently attributed to cardiac failure. Considering that abnormal placental development has been described in congenital heart disease, our hypothesis is that placental insufficiency may contribute to fetal death in congenital heart disease. OBJECTIVE This study aimed to assess cases with fetal congenital heart disease and intrauterine demise, and analyze factors that are related to the demise. STUDY DESIGN All congenital heart disease cases diagnosed prenatally during the period January 2002 to January 2021 were selected from the regional prospective congenital heart disease registry, PRECOR. Multiple pregnancies and pregnancies with fetal trisomy 13 or 18, triploidy, and Turner's syndrome were excluded from the analysis, because fetal demise is attributed to the chromosomal abnormality in these cases. Cases were categorized into 4 groups based on the possible cause of fetal death as follows: cardiac failure, additional (genetic) diagnosis, placental insufficiency, and a group in which no cause was found. A separate analysis was performed for isolated congenital heart disease cases. RESULTS Of the 4806 cases in the PRECOR registry, 112 had fetal demise, of which 43 were excluded from the analysis (13 multiple pregnancies, 30 genetic). Of these, 47.8% were most likely related to cardiac failure, 42.0% to another (genetic) diagnosis, and 10.1% to placental insufficiency. No cases were allocated to the group with an unknown cause. Only 47.8% of the cases had isolated congenital heart disease, and in this group 21.2% was most likely related to placental insufficiency. CONCLUSION This study shows that in addition to cardiac failure and other (genetic) diagnoses, placental factors play an important role in fetal demise in congenital heart disease, especially in cases of isolated heart defects. Therefore, these findings support the importance of regular ultrasonographic assessment of fetal growth and placental function in fetal congenital heart disease.
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Affiliation(s)
- Maartje C Snoep
- Department of Obstetrics and Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands (Drs. Snoep, Drs. Zwanenburg, and Prof. Haak).
| | - Bo B Bet
- Department of Obstetrics and Fetal Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands (Drs. Bet, Drs. Linskens, and Prof. Pajkrt)
| | - Fleur Zwanenburg
- Department of Obstetrics and Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands (Drs. Snoep, Drs. Zwanenburg, and Prof. Haak)
| | - Ingmar Knobbe
- Department of Pediatric Cardiology, Leiden University Medical Center, Leiden, The Netherlands (Drs. Knobbe and Drs. Rozendaal)
| | - Ingeborg H Linskens
- Department of Obstetrics and Fetal Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands (Drs. Bet, Drs. Linskens, and Prof. Pajkrt)
| | - Eva Pajkrt
- Department of Obstetrics and Fetal Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands (Drs. Bet, Drs. Linskens, and Prof. Pajkrt)
| | - Lieke Rozendaal
- Department of Pediatric Cardiology, Leiden University Medical Center, Leiden, The Netherlands (Drs. Knobbe and Drs. Rozendaal)
| | - Lotte E Van der Meeren
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands (Drs. Van der Meeren); Department of Pathology, Erasmus Medical Center, Rotterdam, The Netherlands (Drs. Van der Meeren)
| | - Sally-Ann Clur
- Department of Pediatric Cardiology, Amsterdam University Medical Center, Amsterdam, The Netherlands (Drs. Clur)
| | - Monique C Haak
- Department of Obstetrics and Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands (Drs. Snoep, Drs. Zwanenburg, and Prof. Haak)
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9
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Jepson BM, Metz TD, Miller TA, Son SL, Ou Z, Presson AP, Nance A, Pinto NM. Pregnancy loss in major fetal congenital heart disease: incidence, risk factors and timing. Ultrasound Obstet Gynecol 2023; 62:75-87. [PMID: 37099500 DOI: 10.1002/uog.26231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 03/09/2023] [Accepted: 04/14/2023] [Indexed: 06/19/2023]
Abstract
OBJECTIVE Fetuses with congenital heart disease (CHD) are at increased risk of pregnancy loss compared with the general population. We aimed to assess the incidence, timing and risk factors of pregnancy loss in cases with major fetal CHD, overall and according to cardiac diagnosis. METHODS This was a retrospective, population-level cohort study of fetuses and infants diagnosed with major CHD between 1997 and 2018 identified by the Utah Birth Defect Network (UBDN), excluding cases with termination of pregnancy and minor cardiovascular diagnoses (e.g. isolated aortic/pulmonary pathology and isolated septal defects). The incidence and timing of pregnancy loss were recorded, overall and according to CHD diagnosis, with further stratification based on presence of isolated CHD vs additional fetal diagnosis (genetic diagnosis and/or extracardiac malformation). Adjusted risk of pregnancy loss was calculated and risk factors were assessed using multivariable models for the overall cohort and prenatal diagnosis subgroup. RESULTS Of 9351 UBDN cases with a cardiovascular code, 3251 cases with major CHD were identified, resulting in a study cohort of 3120 following exclusion of cases with pregnancy termination (n = 131). There were 2956 (94.7%) live births and 164 (5.3%) cases of pregnancy loss, which occurred at a median gestational age of 27.3 weeks. Of study cases, 1848 (59.2%) had isolated CHD and 1272 (40.8%) had an additional fetal diagnosis, including 736 (57.9%) with a genetic diagnosis and 536 (42.1%) with an extracardiac malformation. The observed incidence of pregnancy loss was highest in the presence of mitral stenosis (< 13.5%), hypoplastic left heart syndrome (HLHS) (10.7%), double-outlet right ventricle with normally related great vessels or not otherwise specified (10.5%) and Ebstein's anomaly (9.9%). The adjusted risk of pregnancy loss was 5.3% (95% CI, 3.7-7.6%) in the overall CHD population and 1.4% (95% CI, 0.9-2.3%) in cases with isolated CHD (adjusted risk ratio, 9.0 (95% CI, 6.0-13.0) and 2.0 (95% CI, 1.0-6.0), respectively, based on the general population risk of 0.6%). On multivariable analysis, variables associated with pregnancy loss in the overall CHD population included female fetal sex (adjusted odds ratio (aOR), 1.6 (95% CI, 1.1-2.3)), Hispanic ethnicity (aOR, 1.6 (95% CI, 1.0-2.5)), hydrops (aOR, 6.7 (95% CI, 4.3-10.5)) and additional fetal diagnosis (aOR, 6.3 (95% CI, 4.1-10)). On multivariable analysis of the prenatal diagnosis subgroup, years of maternal education (aOR, 1.2 (95% CI, 1.0-1.4)), presence of an additional fetal diagnosis (aOR, 2.7 (95% CI, 1.4-5.6)), atrioventricular valve regurgitation ≥ moderate (aOR, 3.6 (95% CI, 1.3-8.8)) and ventricular dysfunction (aOR, 3.8 (95% CI, 1.2-11.1)) were associated with pregnancy loss. Diagnostic groups associated with pregnancy loss were HLHS and variants (aOR, 3.0 (95% CI, 1.7-5.3)), other single ventricles (aOR, 2.4 (95% CI, 1.1-4.9)) and other (aOR, 0.1 (95% CI, 0-0.97)). Time-to-pregnancy-loss analysis demonstrated a steeper survival curve for cases with an additional fetal diagnosis, indicating a higher rate of pregnancy loss compared to cases with isolated CHD (P < 0.0001). CONCLUSIONS The risk of pregnancy loss is higher in cases with major fetal CHD compared with the general population and varies according to CHD type and presence of additional fetal diagnoses. Improved understanding of the incidence, risk factors and timing of pregnancy loss in CHD cases should inform patient counseling, antenatal surveillance and delivery planning. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- B M Jepson
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - T D Metz
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT, USA
| | - T A Miller
- Division of Pediatric Cardiology, Maine Medical Center, Portland, ME, USA
| | - S L Son
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Colorado, Aurora, CO, USA
| | - Z Ou
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - A P Presson
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - A Nance
- Utah Birth Defect Network, Office of Children with Special Healthcare Needs, Division of Family Health, Utah Department of Health and Human Services, Salt Lake City, UT, USA
| | - N M Pinto
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
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Rotholz S, Lin CT. "I don't think it should take you three days to tell me my baby is dead." A case of fetal demise: unintended consequences of immediate release of information. J Am Med Inform Assoc 2023:7148302. [PMID: 37130346 DOI: 10.1093/jamia/ocad074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 04/04/2023] [Accepted: 04/20/2023] [Indexed: 05/04/2023] Open
Abstract
The 21st Century Cures Act (Cures Act) information blocking regulations mandate timely patient access to their electronic health information. In most healthcare systems, this technically requires immediate electronic release of test results and clinical notes directly to patients. Patients could potentially be distressed by receiving upsetting results through an electronic portal rather than from a clinician. We present a case from 2018, several years prior to the implementation of the Cures Act. A patient was notified of fetal demise detected by ultrasound through her electronic health record (EHR) patient portal before her clinician received the result. We discuss the patient's ensuing complaint and healthcare system response. This unusual and dramatic case of fetal demise is relevant today because it underscores the importance of involving a patient and family advisory council in decision-making. It also highlights the value of "anticipatory guidance" as a routine clinical practice in this era of immediate access to test results.
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Affiliation(s)
- Stephen Rotholz
- Department of Obstetrics & Gynecology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Chen-Tan Lin
- Internal Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
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11
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Alcover N, Regiroli G, Benachi A, Vauloup-fellous C, Vivanti AJ, De luca D. Systematic review and synthesis of stillbirths and late miscarriages following SARS-CoV-2 infections. Am J Obstet Gynecol 2023:S0002-9378(23)00026-1. [PMID: 36706855 PMCID: PMC9872559 DOI: 10.1016/j.ajog.2023.01.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 01/07/2023] [Accepted: 01/17/2023] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To describe the characteristics of fetal demises following SARS-CoV-2 infections and clarify if they are associated with clinical severity, placental lesions or malformations or due to actual fetal infections. DATA SOURCES PubMed and Web of Science databases (searched between December 1, 2019 and April 30, 2022). STUDY ELIGIBILITY CRITERIA Cohort, cross-sectional and case-control studies, as well as case series or case reports describing stillbirths or late miscarriages (i.e. pregnancy loss occurring between 14 and 22 weeks, before and after the onset of labor, respectively) from mothers infected by SARS-CoV-2 during pregnancy (demonstrated by at least one positive real-time reverse transcription polymerase chain reaction on nasopharyngeal swabs, and/or placental infection with SARS-CoV-2). No language restrictions were applied; cases with other causes possibly explaining the fetal demise were excluded. STUDY APPRAISAL AND SYNTHESIS METHODS PRISMA and MOOSE guidelines were followed. Quality of case series/reports was evaluated with the specific Mayo Clinic Evidence-Based Practice Center tool. Maternal and clinical fetal data were collected as well as placental and fetal virology and histology findings. Data were summarized with descriptive statistics using World Health Organization criteria to classify disease severity and fetal-neonatal infections. RESULTS Data from 184 mothers and 190 fetuses were analyzed. No clear link with maternal clinical severity or fetal malformation was evident. Approximately 78% of fetal demises occurred during the second and third trimester, ≈6 and 13 days after diagnosis of SARS-CoV-2 infection or the beginning of symptoms, respectively. Most (88%) placentas were positive for SARS-CoV-2 or presented the histological features of placentitis (massive fibrin deposition and chronic intervillositis) previously observed in transplacentally transmitted infections (≈85-91%). Eleven (5.8%) and 114 (60%) fetuses had a confirmed or possible in utero transmitted SARS-CoV-2 infection, respectively. CONCLUSIONS The synthesis of available data shows that fetal demises generally occur a few days after the infection with histological placental inflammatory lesions associated with transplacental SARS-CoV-2 transmission and eventually causing placental insufficiency.
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Affiliation(s)
- Noemi Alcover
- Division of Obstetrics and Gynecology, “Antoine Béclère” Hospital, Paris Saclay University Hospitals, APHP (Clamart – France)
| | - Giulia Regiroli
- Division of Pediatrics and Neonatal Critical Care, “Antoine Béclère” Hospital, Paris Saclay University Hospitals, APHP (Clamart – France)
| | - Alexandra Benachi
- Division of Obstetrics and Gynecology, “Antoine Béclère” Hospital, Paris Saclay University Hospitals, APHP (Clamart – France)
| | - Christelle Vauloup-fellous
- Division of Virology, “Paul Brousse” Hospital, Paris Saclay University Hospitals, APHP (Villejuif, France)
| | - Alexandre J. Vivanti
- Division of Obstetrics and Gynecology, “Antoine Béclère” Hospital, Paris Saclay University Hospitals, APHP (Clamart – France)
| | - Daniele De luca
- Division of Pediatrics and Neonatal Critical Care, “Antoine Béclère” Hospital, Paris Saclay University Hospitals, APHP (Clamart – France),Corresponding author: Prof. Daniele De Luca, Division of Pediatrics and Neonatal Critical Care Hôpital Antoine Béclère, 157 rue de la porte de Trivaux, 92140 Clamart, +33145474444
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Oualiken C, Martz O, Idrissi N, Harizay FT, Martin L, De Maistre E, Ricaud L, Tarris G. Case report: Umbilical vessel aneurysm thrombosis and factor V Leiden mutation leading to fetal demise. Front Med (Lausanne) 2023; 9:1083806. [PMID: 36687456 PMCID: PMC9845932 DOI: 10.3389/fmed.2022.1083806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 12/09/2022] [Indexed: 01/05/2023] Open
Abstract
Complicated pregnancies are nowadays a major public health concern, with possible lethality or sequelae both for the mother and the fetus. Blood coagulation disorders (including antiphospholipid syndrome, factor V Leiden mutation and antithrombin deficiency) and hypertensive gestational disorders are very well-known contributors of complicated pregnancies with poor fetal outcome, such as intrauterine growth retardation (IUGR) and fetal demise. Less commonly, vascular malformations of the placenta can also potentially lead to serious complications such as IUGR and fetal death. These malformations include hypercoiled umbilical cord, umbilical cord knot, umbilical cord varix, umbilical cord arterial or venous aneurysm, and velamentous insertion of the umbilical cord potentially leading to Benckiser's hemorrhage. Here, we report the case of a 29-year-old Gravida 2 Para 0 mother with previous history of stillbirth and smoking, admitted to the obstetrics department for the absence of fetal movement at 38 weeks of amenorrhea (WA). First-trimester and second-trimester routine ultrasounds were otherwise normal. Ultrasound performed at 38 WA revealed a 83 × 66 × 54 mm cystic heterogenous mass at the umbilical cord insertion. After delivery, fetal and placental pathology as well as maternal blood testing were performed. Fetal pathology was otherwise normal, except for diffuse congestion and meconial overload suggesting acute fetal distress. Fetal karyotype was normal (46 XX). Placental pathology revealed an umbilical artery aneurysm (UAA) at the base of the insertion of the umbilical cord, lined with a CD34+ CD31+ endothelium. After dissection, the aneurysm was filled with hemorrhagic debris, indicating aneurysm thrombosis. Histopathology revealed associated maternal vascular malperfusion (MVM) and increased peri-villous fibrin (IPF). Maternal blood tests revealed heterozygous factor V Leiden mutation, without other associated auto-immune conditions (such as antiphospholipid syndrome). Umbilical artery aneurysms remain extremely rare findings in the placenta, with <20 reported cases. Umbilical artery aneurysms have tendency to be located at the base of the insertion of the placenta, and lead to fetal demise in more than 60% of cases, mainly due to aneurysmal thrombosis, hematoma, possible vascular compression and/or rupture. Umbilical vessel aneurysms can be associated with trisomy 18 or 13. In our case, the association of factor V Leiden mutation, a hypercoagulable state, with UAA could explain massive thrombosis of the aneurysmal lumen and sudden fetal demise. Further consideration of current guidelines for surveillance and management of UAA would allow appropriate planned delivery in maternal care settings.
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Affiliation(s)
- Camélia Oualiken
- Department of Pathology, University Hospital of Dijon, Dijon, France,Forensics Institute, University Hospital of Dijon, Dijon, France
| | - Olivia Martz
- Department of Obstetrics and Gynecology, Prenatal Diagnostic Center, Gynecology Emergency Services, University Hospital of Dijon, Dijon, France
| | | | | | - Laurent Martin
- Department of Pathology, University Hospital of Dijon, Dijon, France
| | | | - Lou Ricaud
- Department of Obstetrics and Gynecology, Prenatal Diagnostic Center, Gynecology Emergency Services, University Hospital of Dijon, Dijon, France
| | - Georges Tarris
- Department of Pathology, University Hospital of Dijon, Dijon, France,*Correspondence: Georges Tarris ✉
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Ghesh L, Désir J, Haye D, Le Tanno P, Devillard F, Cogné B, Marangoni M, Tecco L, Heron D, Le Vaillant C, Joubert M, Beneteau C. Perinatal presentations of non-immune hydrops fetalis due to recessive PIEZO1 disease: A challenging fetal diagnosis. Clin Genet 2022; 103:560-565. [PMID: 36453701 DOI: 10.1111/cge.14274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 11/28/2022] [Accepted: 11/29/2022] [Indexed: 12/03/2022]
Abstract
Hydrops fetalis is a rare disorder associated with significant perinatal complications and a high perinatal mortality of at least 50%. Nonimmune hydrops fetalis (NIHF) is more frequent and results from a wide variety of etiologies. One cause of NIHF is lymphatic malformation 6 (LMPHM6) due to biallelic loss-of-function (LoF) variants in PIEZO1. Most individuals are diagnosed postnatally and only few clinical data are available on fetal presentations. We report six novel biallelic predicted LoF variants in PIEZO1 identified by exome sequencing in six fetuses and one deceased neonate from four unrelated families affected with LMPHM6. During the pregnancy, most cases are revealed by isolated NIHF at second trimester of gestation. At post-mortem examination ascites, pleural effusions and telengectasies can guide the etiological diagnosis. We aim to further describe the perinatal presentation of this condition which could be underdiagnosed.
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Affiliation(s)
- Leïla Ghesh
- CHU de Nantes, UF 9321 de Fœtopathologie et Génétique, Nantes, France
| | - Julie Désir
- Service de Génétique Médicale, Hôpital Erasme - Cliniques Universitaires de Bruxelles, Brussels, Belgium
| | - Damien Haye
- Service de Génétique Médicale, Hospices Civils de Lyon, Lyon, France
| | - Pauline Le Tanno
- Département de Génétique et Procréation, Hôpital Couple-Enfant, CHU de Grenoble, Grenoble, France
| | - Françoise Devillard
- Département de Génétique et Procréation, Hôpital Couple-Enfant, CHU de Grenoble, Grenoble, France
| | - Benjamin Cogné
- CHU de Nantes, UF 9321 de Fœtopathologie et Génétique, Nantes, France
| | - Martina Marangoni
- Laboratoire de Génétique Moléculaire, Hôpital Erasme - Cliniques Universitaires de Bruxelles, Brussels, Belgium
| | - Laura Tecco
- Service de Gynécologie-Obstétrique, Centre Hospitalier Universitaire Saint Pierre, Brussels, Belgium
| | - Delphine Heron
- Service de Génétique Médicale, Centre de Référence "Déficiences Intellectuelles", Hôpitaux Universitaires Pitié Salpêtrière - Charles Foix, Paris, France
| | - Claudine Le Vaillant
- CHU de Nantes, Service de Gynécologie-Obstétrique, Diagnostic Anténatal, Nantes, France
| | - Madeleine Joubert
- CHU de Nantes, UF 9321 de Fœtopathologie et Génétique, Nantes, France
| | - Claire Beneteau
- CHU de Nantes, UF 9321 de Fœtopathologie et Génétique, Nantes, France
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Skeith L, Hurd K, Chaturvedi S, Chow L, Nicholas J, Lee A, Young D, Goodyear D, Soucie J, Girard L, Dufour A, Agbani EO. Hypercoagulability and Inflammatory Markers in a Case of Congenital Thrombotic Thrombocytopenic Purpura Complicated by Fetal Demise. J Clin Med 2022; 11. [PMID: 36498688 DOI: 10.3390/jcm11237115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 11/29/2022] [Accepted: 11/29/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Congenital thrombotic thrombocytopenic purpura (cTTP) is a rare disorder caused by an inherited genetic deficiency of ADAMTS13 and affects less than one per million individuals. Patients who are diagnosed with TTP during pregnancy are at increased risk of maternal and fetal complications including fetal demise. We present a case of a 32-year-old G3P0 (gravida 3, para 0) who presented at 20 weeks gestation with a new diagnosis of congenital TTP (cTTP) and fetal demise. METHODS We describe the pathophysiology of pregnancy complications in a patient with cTTP using platelet procoagulant membrane dynamics analysis and quantitative proteomic studies, compared to four pregnant patients with gestational hypertension, four pregnant patients with preeclampsia, and four healthy pregnant controls. RESULTS The cTTP patient had increased P-selectin, tissue factor expression, annexin-V binding on platelets and neutrophils, and localized thrombin generation, suggestive of hypercoagulability. Among 15 proteins that were upregulated, S100A8 and S100A9 were distinctly overexpressed. CONCLUSIONS There is platelet-neutrophil activation and interaction, platelet hypercoagulability, and proinflammation in our case of cTTP with fetal demise.
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15
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Couck I, van der Merwe J, Russo F, Richter J, Aertsen M, Cauwberghs B, Van Aelst M, Lewi L. Umbilical venous diameter and flow in monochorionic diamniotic twin pregnancy: association with placental sharing and fetal demise. Ultrasound Obstet Gynecol 2022; 60:514-522. [PMID: 35316571 DOI: 10.1002/uog.24903] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 03/03/2022] [Accepted: 03/14/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVE To examine the association of umbilical venous diameter and flow in monochorionic diamniotic twin pregnancy with placental sharing and fetal demise. METHODS This was a prospective longitudinal cohort study of a consecutive series of monochorionic diamniotic twin pregnancies that underwent ultrasound assessments at 12, 16, 20 and 28 weeks' gestation. Fetal biometry (crown-rump length at 12 weeks or estimated fetal weight (EFW) thereafter) and cord insertion sites were recorded at each visit, as well as the diameter of the umbilical vein (UV) in both the intra-abdominal part and a free loop of the umbilical cord. Time-averaged maximum velocity in the intra-abdominal part of the UV was measured to calculate UV-flow. Univariate and multivariate linear regression analyses were performed to assess the relationship between intertwin ratios of these variables and placental sharing at 12, 16, 20 and 28 weeks' gestation. Placental sharing was calculated by dividing the larger by the smaller placental share, as measured on placental injection studies after birth. Additionally, the Mann-Whitney U-test and receiver-operating-characteristics-curve analysis were used to explore the relationship between the occurrence of fetal demise and intertwin differences in fetal biometry, cord insertion sites, UV diameters and flow at 12, 16, 20 and 28 weeks. RESULTS Of 200 consecutive monochorionic twin pregnancies enrolled, injection studies were performed in 165 (82.5%) placentas. On univariate analysis, intertwin differences in fetal biometry, cord insertions and UV variables were associated significantly with placental sharing at 12, 16, 20 and 28 weeks' gestation. On multivariate analysis, intertwin differences in fetal biometry, cord insertions and all three UV variables remained associated significantly with placental sharing at 12 and 16 weeks. However, at 20 and 28 weeks, only the intertwin EFW ratio was associated consistently with placental sharing. Fetal demise of one or both twins complicated 26 (13.0%) pregnancies. Differences in EFW and cord insertion sites were not associated significantly with fetal demise, while at 16 weeks, differences in intra-abdominal UV diameter and flow were associated with an increased risk of subsequent fetal demise. CONCLUSIONS At 12 and 16 weeks' gestation, intertwin differences in UV diameter and flow reflect placental sharing more accurately than do differences in fetal growth and cord insertion sites. At 16 weeks, discordance in intra-abdominal UV diameter and flow is also associated with an increased risk of fetal demise. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- I Couck
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
| | - J van der Merwe
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
| | - F Russo
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
| | - J Richter
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - M Aertsen
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium
- Department of Imaging and Pathology, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | | | - M Van Aelst
- Faculty of Medicine, KU Leuven, Leuven, Belgium
| | - L Lewi
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
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Mustafa HJ, Javinani A, Goetzinger K, Aghajani F, Harman C, Shamshirsaz AA, Sanz Cortes M, Donepudi RV, Krispin E, Nassr AA, Espinoza J, Belfort MA, Turan OM. Single fetal demise following fetoscopic ablation for twin-to-twin transfusion syndrome-cohort study, systematic review, and meta-analysis. Am J Obstet Gynecol 2022; 226:843.e1-843.e28. [PMID: 35257668 DOI: 10.1016/j.ajog.2022.02.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 02/27/2022] [Accepted: 02/28/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Several studies have assessed preoperative and operative factors associated with fetal demise after laser for TTTS, yet these findings are not completely conclusive. OBJECTIVE This study aimed to identify risk factors for single fetal demise (recipient and donor twins) after fetoscopic laser photocoagulation for twin-to-twin transfusion syndrome. STUDY DESIGN We searched PubMed, Scopus, and Web of Science systematically from the inception of the database to June 2020. We conducted a systemic review on studies investigating risk factors for fetal demise (donor and/or recipient) after fetoscopic laser photocoagulation in monochorionic pregnancies complicated with twin-to-twin transfusion syndrome. Initially, we investigated the cohort of women with twin-to-twin transfusion syndrome that underwent fetoscopic laser photocoagulation at our 2 high-volume fetal centers between 2012 and 2020 to identify risk factors for donor demise and recipient demise. Furthermore, we conducted a systematic review of the literature to better characterize these factors. Among studies that met the entry criteria, multiple preoperative and operative factors were tabulated. The random-effect model was used to pool the standardized mean differences or odds ratios and corresponding 95% confidence intervals. Heterogeneity was assessed using the I2 value. RESULTS A total of 514 pregnancies with twin-to-twin transfusion syndrome managed with fetoscopic laser photocoagulation were included in the final analysis. Following the logistic regression, factors that remained significant for donor demise were selective fetal growth restriction (odds ratio, 1.9; 95% confidence interval, 1.3-2.8; P=.001) and umbilical artery blood flow with absent or reversed end-diastolic velocity of the donor (odds ratio, 2.06; 95% confidence interval, 1.2-3.4; P=.004). A significant factor associated with recipient demise was absent or reversed a-wave in the ductus venosus of the recipient (odds ratio, 1.74; 95% confidence interval, 1.07-3.13; P=.04). Data from 23 studies and our current cohort were included. A total of 4892 pregnancies with twin-to-twin transfusion syndrome managed with fetoscopic laser photocoagulation were analyzed for risk factors for donor demise, and 4594 pregnancies with twin-to-twin transfusion syndrome were analyzed for recipient demise. Among studies, the overall incidence rates ranged from 10.9% to 35.8% for donor demise and 7.3% to 24.5% for recipient demise. Significant risk factors for donor demise were intertwin estimated fetal weight discordance of >25% (odds ratio, 1.86; 95% confidence interval, 1.44-2.4; I2, 0.0%), selective fetal growth restriction (odds ratio, 1.78; 95% confidence interval, 1.4-2.27; I2, 0.0%), twin-to-twin transfusion syndrome stage III (odds ratio, 2.18; 95% confidence interval, 1.53-3.12; I2, 0.0%), umbilical artery blood flow with absent or reversed end-diastolic velocity of the donor (odds ratio, 2.31; 95% confidence interval, 1.9-2.8; I2, 23.7%), absent or reversed a-wave in the ductus venosus of the donor (odds ratio, 1.83; 95% confidence interval, 1.45-2.3; I2, 0.0%), and presence of arterioarterial anastomoses (odds ratio, 2.81; 95% confidence interval, 1.35-5.85; I2, 90.7%). Sequential selective coagulation was protective against donor demise (odds ratio, 0.31; 95% confidence interval, 0.16-0.58; I2, 0.0%). Significant risk factors for recipient demise were twin-to-twin transfusion syndrome stage IV (odds ratio, 2.18; 95% confidence interval, 1.01-4.6; I2, 16.5%), umbilical artery blood flow with absent or reversed end-diastolic velocity of the recipient (odds ratio, 2.68; 95% confidence interval, 1.91-3.74; I2, 0.0%), absent or reversed a-wave in the ductus venosus of the recipient (odds ratio, 2.37; 95% confidence interval, 1.55-3.64; I2, 60.2%), and middle cerebral artery peak systolic velocity of >1.5 multiple of the median (odds ratio, 3.06; 95% confidence interval, 1.36-6.88; I2, 0.0%). CONCLUSION Abnormal blood flow patterns represented by abnormal Doppler studies and low fetal weight were associated with single fetal demise in women with twin-to-twin transfusion syndrome undergoing laser therapy. Although sequential selective coagulation was protective against donor demise, the presence of arterioarterial anastomoses was considerably associated with donor demise. This meta-analysis extensively investigated the association of a wide range of preoperative and operative factors with fetal demise. These findings may be important inpatient counseling, in further understanding the disease, and perhaps in improving surgical techniques.
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Jazdarehee A, Huget-Penner S, Pawlowska M. Pseudo-pheochromocytoma due to obstructive sleep apnea: a case report. Endocrinol Diabetes Metab Case Rep 2022; 2022:21-0100. [PMID: 35212265 PMCID: PMC8897593 DOI: 10.1530/edm-21-0100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 02/02/2022] [Indexed: 11/11/2022] Open
Abstract
SUMMARY Obstructive sleep apnea (OSA) is a condition of intermittent nocturnal upper airway obstruction. OSA increases sympathetic drive which may result in clinical and biochemical features suggestive of pheochromocytoma. We present the case of a 65-year-old male with a 2.9-cm left adrenal incidentaloma on CT, hypertension, symptoms of headache, anxiety and diaphoresis, and persistently elevated 24-h urine norepinephrine (initially 818 nmol/day (89-470)) and normetanephrine (initially 11.2 µmol/day (0.6-2.7)). He was started on prazosin and underwent left adrenalectomy. Pathology revealed an adrenal corticoadenoma with no evidence of pheochromocytoma. Over the next 2 years, urine norepinephrine and normetanephrine remained significantly elevated with no MIBG avid disease. Years later, he was diagnosed with severe OSA and treated with continuous positive airway pressure. Urine testing done once OSA was well controlled revealed complete normalization of urine norepinephrine and normetanephrine with substantial symptom improvement. It was concluded that the patient never had a pheochromocytoma but rather an adrenal adenoma with biochemistry and symptoms suggestive of pheochromocytoma due to untreated severe OSA. Pseudo-pheochromocytoma is a rare presentation of OSA and should be considered on the differential of elevated urine catecholamines and metanephrines in the right clinical setting. LEARNING POINTS Obstructive sleep apnea (OSA) is a common condition among adults. OSA may rarely present as pseudo-pheochromocytoma with symptoms of pallor, palpitations, perspiration, headache, or anxiety. OSA should be considered on the differential of elevated urine catecholamines and metanephrines, especially in patients with negative metaiodobenzylguanidine (MIBG) scan results.
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Key Words
- adolescent/young adult
- adult
- geriatric
- neonatal
- paediatric
- pregnant adult
- female
- male
- american indian or alaska native
- asian - bangladeshi
- asian - chinese
- asian - filipino
- asian - indian
- asian - japanese
- asian - korean
- asian - pakistani
- asian - vietnamese
- asian - other
- black - african
- black - caribbean
- black - other
- hispanic or latino - central american or south american
- hispanic or latino - cuban
- hispanic or latino - dominican
- hispanic or latino - mexican, mexican american, chicano
- hispanic or latino - puerto rican
- hispanic or latino - other
- native hawaiian/other pacific islander
- white
- other
- afghanistan
- aland islands
- albania
- algeria
- american samoa
- andorra
- angola
- anguilla
- antarctica
- antigua and barbuda
- argentina
- armenia
- aruba
- australia
- austria
- azerbaijan
- bahamas
- bahrain
- bangladesh
- barbados
- belarus
- belgium
- belize
- benin
- bermuda
- bhutan
- bolivia
- bosnia and herzegovina
- botswana
- bouvet island
- brazil
- british indian ocean territory
- brunei darussalam
- bulgaria
- burkina faso
- burundi
- cambodia
- cameroon
- canada
- cape verde
- cayman islands
- central african republic
- chad
- chile
- china
- christmas island
- cocos (keeling) islands
- colombia
- comoros
- congo
- congo, the democratic republic of the
- cook islands
- costa rica
- côte d'ivoire
- croatia
- cuba
- cyprus
- czech republic
- denmark
- djibouti
- dominica
- dominican republic
- ecuador
- egypt
- el salvador
- equatorial guinea
- eritrea
- estonia
- ethiopia
- falkland islands (malvinas)
- faroe islands
- fiji
- finland
- france
- french guiana
- french polynesia
- french southern territories
- gabon
- gambia
- georgia
- germany
- ghana
- gibraltar
- greece
- greenland
- grenada
- guadeloupe
- guam
- guatemala
- guernsey
- guinea
- guinea-bissau
- guyana
- haiti
- heard island and mcdonald islands
- holy see (vatican city state)
- honduras
- hong kong
- hungary
- iceland
- india
- indonesia
- iran, islamic republic of
- iraq
- ireland
- isle of man
- israel
- italy
- jamaica
- japan
- jersey
- jordan
- kazakhstan
- kenya
- kiribati
- korea, democratic people's republic of
- korea, republic of
- kuwait
- kyrgyzstan
- lao people's democratic republic
- latvia
- lebanon
- lesotho
- liberia
- libyan arab jamahiriya
- liechtenstein
- lithuania
- luxembourg
- macao
- macedonia, the former yugoslav republic of
- madagascar
- malawi
- malaysia
- maldives
- mali
- malta
- marshall islands
- martinique
- mauritania
- mauritius
- mayotte
- mexico
- micronesia, federated states of
- moldova, republic of
- monaco
- mongolia
- montenegro
- montserrat
- morocco
- mozambique
- myanmar
- namibia
- nauru
- nepal
- netherlands
- netherlands antilles
- new caledonia
- new zealand
- nicaragua
- niger
- nigeria
- niue
- norfolk island
- northern mariana islands
- norway
- oman
- pakistan
- palau
- palestinian territory, occupied
- panama
- papua new guinea
- paraguay
- peru
- philippines
- pitcairn
- poland
- portugal
- puerto rico
- qatar
- réunion
- romania
- russian federation
- rwanda
- saint barthélemy
- saint helena
- saint kitts and nevis
- saint lucia
- saint martin
- saint pierre and miquelon
- saint vincent and the grenadines
- samoa
- san marino
- sao tome and principe
- saudi arabia
- senegal
- serbia
- seychelles
- sierra leone
- singapore
- slovakia
- slovenia
- solomon islands
- somalia
- south africa
- south georgia and the south sandwich islands
- spain
- sri lanka
- sudan
- suriname
- svalbard and jan mayen
- swaziland
- sweden
- switzerland
- syrian arab republic
- taiwan, province of china
- tajikistan
- tanzania, united republic of
- thailand
- timor-leste
- togo
- tokelau
- tonga
- trinidad and tobago
- tunisia
- turkey
- turkmenistan
- turks and caicos islands
- tuvalu
- uganda
- ukraine
- united arab emirates
- united kingdom
- united states
- united states minor outlying islands
- uruguay
- uzbekistan
- vanuatu
- vatican city state
- venezuela
- viet nam
- virgin islands, british
- virgin islands, u.s.
- wallis and futuna
- western sahara
- yemen
- zambia
- zimbabwe
- maylaysia
- adipose tissue
- adrenal
- bone
- duodenum
- heart
- hypothalamus
- kidney
- liver
- ovaries
- pancreas
- parathyroid
- pineal
- pituitary
- placenta
- skin
- stomach
- testes
- thymus
- thyroid
- andrology
- autoimmunity
- cardiovascular endocrinology
- developmental endocrinology
- diabetes
- emergency
- endocrine disruptors
- endocrine-related cancer
- epigenetics
- genetics and mutation
- growth factors
- gynaecological endocrinology
- immunology
- infectious diseases
- late effects of cancer therapy
- mineral
- neuroendocrinology
- obesity
- ophthalmology
- paediatric endocrinology
- puberty
- tumours and neoplasia
- vitamin d
- 17ohp
- acth
- adiponectin
- adrenaline
- aldosterone
- amh
- androgens
- androstenedione
- androsterone
- angiotensin
- antidiuretic hormone
- atrial natriuretic hormone
- avp
- beta-endorphin
- big igf2
- brain natriuretic peptide
- calcitonin
- calcitriol
- cck
- corticosterone
- corticotrophin
- cortisol
- cortisone
- crh
- dehydroepiandrostenedione
- deoxycorticosterone
- deoxycortisol
- dhea
- dihydrotestosterone
- dopamine
- endothelin
- enkephalin
- epitestosterone
- epo
- fgf23
- fsh
- gastrin
- gh
- ghrelin
- ghrh
- gip
- glp1
- glp2
- glucagon
- glucocorticoids
- gnrh
- gonadotropins
- hcg
- hepcidin
- histamine
- human placental lactogen
- hydroxypregnenolone
- igf1
- igf2
- inhibin
- insulin
- kisspeptin
- leptin
- lh
- melanocyte-stimulating hormone
- melatonin
- metanephrines
- mineralocorticoids
- motilin
- nandrolone
- neuropeptide y
- noradrenaline
- normetanephrine
- oestetrol (e4)
- oestradiol (e2)
- oestriol (e3)
- oestrogens
- oestrone (e1)
- osteocalcin
- oxyntomodulin
- oxytocin
- pancreatic polypeptide
- peptide yy
- pregnenolone
- procalcitonin
- progesterone
- prolactin
- prostaglandins
- pth
- relaxin
- renin
- resistin
- secretin
- somatostatin
- testosterone
- thpo
- thymosin
- thymulin
- thyroxine (t4)
- trh
- triiodothyronine (t3)
- tsh
- vip
- 17-alpha hydroxylase/17,20 lyase deficiency
- 17-beta-hydroxysteroid dehydrogenase type 3 deficiency
- 3-m syndrome
- 22q11 deletion syndrome
- 49xxxxy syndrome
- abscess
- acanthosis nigricans
- acromegaly
- acute adrenocortical insufficiency
- addisonian crisis
- addison's disease
- adenocarcinoma
- aip gene mutation
- adrenal insufficiency
- adrenal salt-wasting crisis
- adrenarche
- adrenocortical adenoma
- adrenocortical carcinoma
- adrenoleukodystrophy
- aip gene variant
- amenorrhoea (primary)
- amenorrhoea (secondary)
- amyloid goitre
- amyloidosis
- anaplastic thyroid cancer
- anaemia
- aneuploidy
- androgen insensitivity syndrome
- anti-phospholipid antibody syndrome
- asthma
- autoimmune disorders
- autoimmune polyendocrine syndrome 1
- autoimmune polyendocrine syndrome 2
- autoimmune polyglandular syndrome
- autoimmune hypophysitis
- autosomal dominant hypophosphataemic rickets
- autosomal dominant osteopetrosis
- bardet-biedl syndrome
- bartter syndrome
- bilateral adrenal hyperplasia
- biliary calculi
- breast cancer
- brenner tumour
- brown tumour
- burkitt's lymphoma
- casr gene mutation
- catecholamine secreting carotid body paraganglionoma
- cancer-prone syndrome
- carcinoid syndrome
- carcinoid tumour
- carney complex
- carotid body paraganglioma
- c-cell hyperplasia
- cerebrospinal fluid leakage
- chronic fatigue syndrome
- circadian rhythm sleep disorders
- congenital adrenal hyperplasia
- congenital hypothyroidism
- congenital hyperinsulinism
- conn's syndrome
- corticotrophic adenoma
- craniopharyngioma
- cretinism
- crohn's disease
- cryptorchidism
- cushing's disease
- cushing's syndrome
- cystolithiasis
- de quervain's thyroiditis
- denys-drash syndrome
- desynchronosis
- developmental abnormalities
- diabetes - lipoatrophic
- diabetes - mitochondrial
- diabetes - steroid-induced
- diabetes insipidus - dipsogenic
- diabetes insipidus - gestational
- diabetes insipidus - nephrogenic
- diabetes insipidus - neurogenic/central
- diabetes mellitus type 1
- diabetes mellitus type 2
- diabetic foot syndrome
- diabetic hypoglycaemia
- diabetic ketoacidosis
- diabetic muscle infarction
- diabetic nephropathy
- diverticular disease
- donohue syndrome
- down syndrome
- eating disorders
- ectopic acth syndrome
- ectopic cushing's syndrome
- ectopic parathyroid adenoma
- empty sella syndrome
- endometrial cancer
- endometriosis
- eosinophilic myositis
- euthyroid sick syndrome
- familial hypocalciuric hypercalcaemia
- familial dysalbuminaemic hyperthyroxinaemia
- familial euthyroid hyperthyroxinaemia
- fat necrosis
- female athlete triad syndrome
- fetal demise
- fetal macrosomia
- follicular thyroid cancer
- fractures
- frasier syndrome
- friedreich's ataxia
- functional parathyroid cyst
- galactorrhoea
- gastrinoma
- gastritis
- gastrointestinal perforation
- gastrointestinal stromal tumour
- gck mutation
- gender identity disorder
- gestational diabetes mellitus
- giant ovarian cysts
- gigantism
- gitelman syndrome
- glucagonoma
- glucocorticoid remediable aldosteronism
- glycogen storage disease
- goitre
- goitre (multinodular)
- gonadal dysgenesis
- gonadoblastoma
- gonadotrophic adenoma
- gorham's disease
- granuloma
- granulosa cell tumour
- graves' disease
- graves' ophthalmopathy
- growth hormone deficiency (adult)
- growth hormone deficiency (childhood onset)
- gynaecomastia
- hamman's syndrome
- haemorrhage
- hajdu-cheney syndrome
- hashimoto's disease
- hemihypertrophy
- hepatitis c
- hereditary multiple osteochondroma
- hirsutism
- histiocytosis
- huntington's disease
- hürthle cell adenoma
- hyperaldosteronism
- hyperandrogenism
- hypercalcaemia
- hypercalcaemic crisis
- hyperglucogonaemia
- hyperglycaemia
- hypergonadotropic hypogonadism
- hypergonadotropism
- hyperinsulinaemia
- hyperinsulinaemic hypoglycaemia
- hyperkalaemia
- hyperlipidaemia
- hypernatraemia
- hyperosmolar hyperglycaemic state
- hyperparathyroidism (primary)
- hyperparathyroidism (secondary)
- hyperparathyroidism (tertiary)
- hyperpituitarism
- hyperprolactinaemia
- hypersexuality
- hypertension
- hyperthyroidism
- hypoaldosteronism
- hypocalcaemia
- hypoestrogenism
- hypoglycaemia
- hypoglycaemic coma
- hypogonadism
- hypogonadotrophic hypogonadism
- hypoinsulinaemia
- hypokalaemia
- hyponatraemia
- hypoparathyroidism
- hypophosphataemia
- hypophosphatasia
- hypophysitis
- hypopituitarism
- hypothyroidism
- iatrogenic disorder
- idiopathic bilateral adrenal hyperplasia
- idiopathic pituitary hyperplasia
- igg4-related systemic disease
- inappropriate tsh secretion
- incidentaloma
- infertility
- insulin autoimmune syndrome
- insulin resistance
- insulinoma
- intracranial vasospasm
- intrauterine growth retardation
- iodine allergy
- ischaemic heart disease
- kallmann syndrome
- ketoacidosis
- klinefelter syndrome
- kwashiorkor
- kwashiorkor (marasmic)
- leg ulcer
- laron syndrome
- latent autoimmune diabetes of adults (lada)
- laurence-moon syndrome
- left ventricular hypertrophy
- leukocytoclastic vasculitis
- leydig cell tumour
- lipodystrophy
- lipomatosis
- liver failure
- lung metastases
- luteoma
- lymphadenopathy
- macronodular adrenal hyperplasia
- macronodular hyperplasia
- macroprolactinoma
- marasmus
- maturity onset diabetes of young (mody)
- mccune-albright syndrome
- mckittrick-wheelock syndrome
- medullary thyroid cancer
- meigs syndrome
- membranous nephropathy
- men1
- men2a
- men2b
- men4
- menarche
- meningitis
- menopause
- metabolic acidosis
- metabolic syndrome
- metastatic carcinoma
- metastatic chromaffin cell tumour
- metastatic gastrinoma
- metastatic melanoma
- metastatic tumour
- microadenoma
- microprolactinoma
- motor neurone disease
- myasthenia gravis
- myelolipoma
- myocardial infarction
- myositis
- myotonic dystrophy type 1
- myotonic dystrophy type 2
- myxoedema
- myxoedema coma
- nelson's syndrome
- neonatal diabetes
- nephrolithiasis
- neuroblastoma
- neuroendocrine tumour
- neurofibromatosis
- nodular hyperplasia
- non-functioning pituitary adenoma
- non-hodgkin lymphoma
- non-islet-cell tumour hypoglycaemia
- noonan syndrome
- oculocerebrorenal syndrome
- osteogenesis imperfecta
- osteomalacia
- osteomyelitis
- osteoporosis
- osteoporosis (pregnancy/lactation-associated)
- osteosclerosis
- ovarian cancer
- ovarian dysgenesis
- ovarian hyperstimulation syndrome
- ovarian tumour
- paget's disease
- paget's disease (juvenille)
- pancreatic neuroendocrine tumour
- pancreatitis
- panhypopituitarism
- papillary thyroid cancer
- paraganglioma
- paranasal sinus lesion
- paraneoplastic syndromes
- parasitic thyroid nodules
- parathyroid adenoma
- parathyroid adenoma (ectopic)
- parathyroid carcinoma
- parathyroid cyst
- parathroid hyperplasia
- pcos
- periodontal disease
- phaeochromocytoma
- phaeochromocytoma crisis
- pickardt syndrome
- pituitary abscess
- pituitary adenoma
- pituitary apoplexy
- pituitary carcinoma
- pituitary cyst
- pituitary haemorrhage
- pituitary hyperplasia
- pituitary hypoplasia
- pituitary tumour (malignant)
- plurihormonal pituitary adenoma
- poems syndrome
- polycythaemia
- porphyria
- pneumonia
- posterior reversible encephalopathy syndrome
- post-prandial hypoglycaemia
- prader-willi syndrome
- prediabetes
- pre-eclampsia
- pregnancy
- premature ovarian failure
- premenstrual dysphoric disorder
- premenstrual syndrome
- primary hypertrophic osteoarthropathy
- prolactinoma
- prostate cancer
- pseudohypoaldosteronism type 1
- pseudohypoaldosteronism type 2
- pseudohypoparathyroidism
- psychosocial short stature
- puberty (delayed or absent)
- puberty (precocious)
- pulmonary oedema
- quadrantanopia
- rabson-mendenhall syndrome
- rhabdomyolysis
- rheumatoid arthritis
- rickets
- schwannoma
- sellar reossification
- sertoli cell tumour
- sertoli-leydig cell tumour
- sexual development disorders
- sheehan's syndrome
- short stature
- siadh
- small-cell carcinoma
- small intestine neuroendocrine tumour
- solitary fibrous tumour
- solitary sellar plasmacytoma
- somatostatinoma
- somatotrophic adenoma
- squamous cell thyroid carcinoma
- stiff person syndrome
- struma ovarii
- subcutaneous insulin resistance
- systemic lupus erythematosus
- takotsubo cardiomyopathy
- tarts
- testicular cancer
- thecoma
- thyroid adenoma
- thyroid carcinoma
- thyroid cyst
- thyroid dysgenesis
- thyroid fibromatosis
- thyroid hormone resistance syndrome
- thyroid lymphoma
- thyroid nodule
- thyroid storm
- thyroiditis
- thyrotoxicosis
- thyrotrophic adenoma
- traumatic brain injury
- tuberculosis
- tuberous sclerosis complex
- tumour-induced osteomalacia
- turner syndrome
- unilateral adrenal hyperplasia
- ureterolithiasis
- urolithiasis
- von hippel-lindau disease
- wagr syndrome
- waterhouse-friderichsen syndrome
- williams syndrome
- wolcott-rallison syndrome
- wolfram syndrome
- xanthogranulomatous hypophysitis
- xlaad/ipex
- zollinger-ellison syndrome
- abdominal adiposity
- abdominal distension
- abdominal cramp
- abdominal discomfort
- abdominal guarding
- abdominal lump
- abdominal pain
- abdominal tenderness
- abnormal posture
- abdominal wall defects
- abrasion
- acalculia
- accelerated growth
- acne
- acrochorda
- acroosteolysis
- acute stress reaction
- adverse breast development
- aggression
- agitation
- agnosia
- akathisia
- akinesia
- albuminuria
- alcohol intolerance
- alexia
- alopecia
- altered level of consciousness
- amaurosis
- amaurosis fugax
- ambiguous genitalia
- amblyopia
- amenorrhoea
- ameurosis
- amnesia
- amusia
- anasarca
- angiomyxoma
- anhedonia
- anisocoria
- ankle swelling
- anorchia
- anorectal malformations
- anorexia
- anosmia
- anosognosia
- anovulation
- antepartum haemorrhage
- anuria
- anxiety
- apathy
- aphasia
- aphonia
- apnoea
- appendicitis
- appetite increase
- appetite reduction/loss
- apraxia
- aqueductal stenosis
- arteriosclerosis
- arthralgia
- articulation impairment
- ascites
- asperger syndrome
- asphyxia
- asthenia
- astigmatism
- asymptomatic
- ataxia
- atrial fibrillation
- atrial myxoma
- atrophy
- adhd
- autism
- autonomic neuropathy
- avulsion
- babinski's sign
- back pain
- bacteraemia
- behavioural problems
- belching
- bifid scrotum
- biliary colic
- bitemporal hemianopsia
- blindness
- blistering
- bloating
- bloody show
- boil(s)
- bone cyst
- bone fracture(s)
- bone lesions
- bone pain
- bony metastases
- borborygmus
- bowel movements - bleeding
- bowel movements - increased frequency
- bowel movements - pain
- bowel obstruction
- bowel perforation
- brachycephaly
- brachydactyly
- bradycardia
- bradykinesia
- bradyphrenia
- bradypnea
- breast contour change
- breast enlargement
- breast lump
- breast reduction
- breast tenderness
- breastfeeding difficulties
- breathing difficulties
- bronchospasms
- brushfield spots
- bruxism
- buffalo hump
- cachexia
- calcification
- cardiac fibrosis
- cardiac malformations
- cardiac tamponade
- cardiogenic shock
- cardiomegaly
- cardiomyopathy
- cardiopulmonary arrest
- carpal tunnel syndrome
- caruncle - inflammation
- cataplexy
- cataract(s)
- catathrenia
- central obesity
- cerebrospinal fluid rhinorrhoea
- cervical pain
- cheeks - full
- cheiloschisis
- chemosis
- chest pain
- chest pain (pleuritic)
- chest pain (precordial)
- cheyne-stokes respiration
- chills
- cholecystitis
- cholestasis
- chondrocalcinosis
- chordee
- chorea
- choroidal atrophy
- chronic pain
- circulatory collapse
- cirrhosis
- citraturia
- claudication
- clitoromegaly
- cloacal exstrophy
- clonus
- club foot
- clumsiness
- coagulopathy
- coarctation
- coeliac disease
- cognitive problems
- cold intolerance
- collapse
- colour blindness
- coma
- concentration difficulties
- confusion
- congenital heart defect
- conjunctivitis
- constipation
- convulsions
- coordination difficulties
- coughing
- crackles
- cramps
- craniofacial abnormalities
- craniotabes
- cutaneous ischaemia
- cutaneous myxoma
- cutaneous pigmentation
- cyanosis
- dalrymple's sign
- deafness
- deep vein thrombosis
- dehydration
- delayed puberty
- delirium
- dementia
- dental abscess(es)
- dental problems
- depression
- diabetes insipidus
- diabetic neuropathy
- diabetic foot infection
- diabetic foot neuropathy
- diabetic foot ulceration
- diarrhoea
- diplopia
- dizziness
- duodenal atresia
- duplex kidney(s)
- dysarthria
- dysdiadochokinesia
- dysgraphia
- dyslexia
- dyslipidaemia
- dysmenorrhoea
- dyspareunia
- dyspepsia
- dysphagia
- dysphonia
- dysphoria
- dyspnoea
- dystonia
- dysuria
- ear, nose and/or throat infection
- early menarche
- ears - low set
- ears - pinna abnormalities
- ears - small
- ecchymoses
- ectopic ureter
- emotional immaturity
- encopresis
- endometrial hyperplasia
- enlarged bladder
- enlarged prostate
- eosinophilia
- epicanthic fold
- epilepsy
- epistaxis
- erectile dysfunction
- erythema
- euphoria
- eyebrows - bushy
- eyelid retraction
- eyelid swelling
- eyelids - redness
- eyes - almond-shaped
- eyes - dry
- eyes - feeling of grittiness
- eyes - inflammation
- eyes - irritation
- eyes - itching
- eyes - pain (gazing down)
- eyes - pain (gazing up)
- eyes - redness
- eyes - watering
- face - change in appearance
- face - coarse features
- face - numbness
- facial fullness
- facial palsy
- facial plethora
- facial weakness
- facies - abnormal
- facies - hippocratic
- facies - moon
- faecal incontinence
- failure to thrive
- fallopian tube hyperplasia
- fasciculation
- fatigue
- fatigue (post-exertional)
- feet - cold
- feet - increased size
- feet - large
- feet - pain
- feet - small
- fingers - thick
- flaccid paralysis
- flatulence
- flushing
- fontanelles - enlarged
- frontal bossing
- fungating lesion
- fungating mass
- funny turns
- gait abnormality
- gait unsteadiness
- gallbladder calculi
- gallstones
- gangrene
- gastro-oesophageal reflux
- genital oedema
- genu valgum
- genu varum
- gestational diabetes
- glaucoma
- glucose intolerance
- glucosuria
- growth hormone deficiency
- growth retardation
- haematemesis
- haematochezia
- haematoma
- haematuria
- haemoglobinuria
- haemoptysis
- hair - coarse
- hair - dry
- hair - temporal balding
- hairline - low
- hallucination
- hands - enlargement
- hands - large
- hands - single palmar crease
- hands - small
- head - large
- headache
- hearing loss
- heart failure
- heart murmur
- heat intolerance
- height loss
- hemiballismus
- hemianopia
- hemiparesis
- hemispatial neglect
- hepatic cysts
- hepatic metastases
- hepatomegaly
- hidradenitis suppurativa
- high-arched palate
- hip dislocation
- hippocampal dysgenesis
- hirschsprung's disease
- hot flushes
- hydronephrosis
- hypolipidaemia
- hyperactivity
- hyperacusis
- hyperandrogenaemia
- hypercalciuria
- hypercapnea
- hypercholesterolaemia
- hypercortisolaemia
- hyperflexibility
- hyperglucagonaemia
- hyperhidrosis
- hyperhomocysteinaemia
- hypernasal speech
- hyperopia
- hyperoxaluria
- hyperpigmentation
- hyperplasia
- hyperpnoea
- hypersalivation
- hyperseborrhea
- hypersomnia
- hyperthermia
- hypertrichosis
- hypertrophy
- hyperuricaemia
- hyperventilation
- hypoadrenalism
- hypoalbuminaemia
- hypocalciuria
- hypocitraturia
- hypomagnesaemia
- hypopigmentation
- hypoplastic scrotum
- hypopotassaemia
- hypoprolactinaemia
- hyporeflexia
- hyposmia
- hypospadias
- hypotension
- hypothermia
- hypotonia
- hypoventilation
- hypovitaminosis d
- hypovolaemia
- hypovolaemic shock
- hypoxia
- immunodeficiency
- impulsivity
- inattention
- infections
- inflexibility
- insomnia
- instability
- intussusception
- irritability
- ischaemia
- ischuria
- itching
- jaundice
- keratoconus
- ketonuria
- ketotic odour
- kidney dysplasia
- kidney stones
- kyphoscoliosis
- kyphosis
- labioscrotal fold abnormalities
- laceration
- late dentition
- learning difficulties
- leg pain
- legs - increased length
- leukaemia
- leukocytosis
- libido increase
- libido reduction/loss
- lichen sclerosus
- lips - dry
- lips - thin
- little finger - in-curved
- little finger - short
- liver masses
- lordosis
- lordosis (loss of)
- lymphadenectomy
- lymphadenitis
- lymphocytosis
- lymphoedema
- macroglossia
- malaise
- malaise (post-exertional)
- malodorous perspiration
- mania
- marcus gunn pupil
- mastalgia
- meckel's diverticulum
- melena
- menorrhagia
- menstrual disorder
- mesenteric ischaemia
- metabolic alkalosis
- microalbuminuria
- microcephaly
- micrognathia
- micropenis
- milk-alkali syndrome
- miscarriage
- mood changes/swings
- mouth - down-turned
- mouth - small
- movement - limited range of
- mucosal pigmentation
- muscle atrophy
- muscle freezing
- muscle hypertrophy
- muscle rigidity
- myalgia
- myasthaenia
- mydriasis
- myelodysplasia
- myeloma
- myoclonus
- myodesopsia
- myokymia
- myopathy
- myopia
- myosis
- nail clubbing
- nail dystrophy
- nasal obstruction
- nausea
- neck - loose skin (nape)
- neck - short
- neck mass
- neck pain/discomfort
- necrolytic migratory erythema
- necrosis
- nephrocalcinosis
- nephropathy
- neurofibromas
- night terrors
- nipple change
- nipple discharge
- nipple inversion
- nipple retraction
- nipples widely spaced
- nocturia
- normochromic normocytic anaemia
- nose - depressed bridge
- nose - flat bridge
- nose - thickening
- nystagmus
- obsessive-compulsive disorder
- obstetrical haemorrhage
- obstructive sleep apnoea
- odynophagia
- oedema
- oesophageal atresia
- oesophagitis
- oligomenorrhoea
- oliguria
- onychauxis
- oophoritis
- ophthalmoplegia
- optic atrophy
- orbital fat prolapse
- orbital hypertelorism
- orthostatic hypotension
- osteoarthritis
- osteopenia
- otitis media
- ovarian cysts
- ovarian hyperplasia
- palatoschisis
- pallor
- palmar erythema
- palpebral fissure (downslanted)
- palpebral fissure (extended)
- palpebral fissure (reduced)
- palpebral fissure (upslanted)
- palpitations
- pancreatic fibrosis
- pancytopaenia
- panic attacks
- papilloedema
- paraesthesia
- paralysis
- paranoia
- patellar dislocation
- patellar subluxation
- pedal ulceration
- pellagra
- pelvic mass
- pelvic pain
- penile agenesis
- peptic ulcer
- pericardial effusion
- periodontitis
- periosteal bone reactions
- peripheral oedema
- personality change
- pes cavus
- petechiae
- peyronie's disease
- pharyngitis
- philtrum - long
- philtrum - short
- phosphaturia
- photophobia
- photosensitivity
- pleurisy
- poikiloderma
- polydactyly
- polydipsia
- polyphagia
- polyuria
- poor wound healing
- postmenopausal bleeding
- post-nasal drip
- postprandial fullness
- postural instability
- prehypertension
- premature birth
- premature labour
- prenatal growth retardation
- presbyopia
- pretibial myxoedema
- proctalgia fugax
- prognathism
- proptosis
- prosopagnosia
- proteinuria
- pruritus
- pruritus scroti
- pruritus vulvae
- pseudarthrosis
- psoriatic arthritis
- psychiatric problems
- psychomotor retardation
- psychosis
- pterygium colli
- ptosis
- puberty (delayed/absent)
- puberty (early/precocious)
- puffiness
- pulmonary embolism
- purpura
- pyelonephritis
- pyloric stenosis
- pyrexia
- pyrosis
- pyuria
- rash
- rectal pain
- rectorrhagia
- refractory anemia
- reluctance to weight-bear
- renal agenesis
- renal clubbing
- renal colic
- renal cyst
- renal failure
- renal insufficiency
- renal phosphate wasting (isolated)
- renal tubular acidosis
- respiratory failure
- reticulocytosis
- retinitis pigmentosa
- retinopathy
- retrobulbar pain
- retrograde ejaculation
- retroperitoneal fibrosis
- salivary gland swelling
- salpingitis
- salt craving
- salt wasting
- sarcoidosis
- schizophrenia
- scoliosis
- scotoma
- seborrhoeic dermatitis
- seizures
- sensory loss
- sepsis
- septic arthritis
- septic shock
- shivering
- singultus
- sinusitis
- sixth nerve palsy
- skeletal deformity
- skeletal dysplasia
- skin - texture change
- skin infections
- skin necrosis
- skin pigmentation - spotty
- skin thickening
- skin thinning
- sleep apnoea
- sleep difficulties
- sleep disturbance
- sleep hyperhidrosis
- slow growth
- slurred speech
- social difficulties
- soft tissue swelling
- somnambulism
- somniloquy
- somnolence
- sore throat
- spasms
- spastic paraplegia
- spasticity
- speech delay
- spider naevi
- splenomegaly
- sputum production
- steatorrhoea
- stomatitis
- strabismus
- strangury
- striae
- stridor
- stroke
- subfertility
- suicidal ideation
- supraclavicular fat pads
- supranuclear gaze palsy
- sweating
- syncope
- syndactyly
- tachycardia
- tachypnoea
- teeth gapping
- telangiectasias
- telecanthus
- tetraparesis
- t-reflex (absent)
- t-reflex (depressed)
- tetany
- thermodysregulation
- thrombocytopenia
- thrombocytosis
- thrombophilia
- thrush
- tics
- tinnitus
- toe clubbing
- toe deformities
- toes - thick
- toes - widely spaced
- tongue - protruding
- tracheo-oesophageal compression
- tracheo-oesophageal fistula
- tremulousness
- tricuspid insufficiency
- umbilical hernia
- uraemia
- ureter duplex
- uricaemia
- urinary frequency
- urinary incontinence
- urogenital sinus
- urticaria
- uterine hyperplasia
- uterus duplex
- vagina duplex
- vaginal bleeding
- vaginal discharge
- vaginal dryness
- vaginal pain/tenderness
- vaginism
- ventricular fibrillation
- ventricular hypertrophy
- vertigo
- viraemia
- virilisation (abnormal)
- vision - acuity reduction
- vision - blurred
- visual disturbance
- visual field defect
- visual impairment
- visual loss
- vitiligo
- vocal cord paresis
- vomiting
- von graefe's sign
- weight gain
- weight loss
- wheezing
- widened joint space(s)
- xeroderma
- xerostomia
- 3-methoxy 4-hydroxy mandelic acid
- 17-hydroxypregnenolone (urine)
- 17-ketosteroids
- 25-hydroxyvitamin-d3
- 5hiaa
- aberrant adrenal receptors
- acid-base balance
- acth stimulation
- activated partial thromboplastin time
- acyl-ghrelin
- adrenal antibodies
- adrenal function
- adrenal scintigraphy
- adrenal venous sampling
- afp tumour marker
- alanine aminotransferase
- albumin
- albumin to creatinine ratio
- aldosterone (24-hour urine)
- aldosterone (blood)
- aldosterone (plasma)
- aldosterone (serum)
- aldosterone to renin ratio
- alkaline phosphatase
- alkaline phosphatase (bone-specific)
- alpha-fetoprotein
- ammonia
- amniocentesis
- amylase
- angiography
- anion gap
- anti-acetylcholine antibodies
- anticardiolipin antibody
- anti-insulin antibodies
- anti-islet cell antibody
- anti-gh antibodies
- antinuclear antibody
- anti-tyrosine phosphatase antibodies
- asvs
- barium studies
- basal insulin
- base excess
- apolipoprotein h
- beta-hydroxybutyrate
- bicarbonate
- bilirubin
- biopsy
- blood film
- blood pressure
- bmi
- body fat mass
- bone age
- bone biopsy
- bone mineral content
- bone mineral density
- bone mineral density test
- bone scintigraphy
- bone sialoprotein
- bound insulin
- brca1/brca2
- c1np
- c3 complement
- c4 complement
- ca125
- calcifediol
- calcium (serum)
- calcium (urine)
- calcium to creatinine clearance ratio
- carcinoembryonic antigen
- cardiac index
- catecholamines (24-hour urine)
- catecholamines (plasma)
- cd-56
- chemokines
- chest auscultation
- chloride
- chorionic villus sampling
- chromatography
- chromogranin a
- chromosomal analysis
- clomid challenge
- clonidine suppression
- collagen
- colonoscopy
- colposcopy
- continuous glucose monitoring
- core needle biopsy
- corticotropin-releasing hormone stimulation test
- cortisol (9am)
- cortisol (plasma)
- cortisol (midnight)
- cortisol (salivary)
- cortisol (serum)
- cortisol day curve
- cortisol, free (24-hour urine)
- c-peptide (24-hour urine)
- c-peptide (blood)
- c-reactive protein
- creatinine
- creatine kinase
- creatinine (24-hour urine)
- creatinine (serum)
- creatinine clearance
- crh stimulation
- ctpa scan
- ct scan
- c-telopeptide
- cytokines
- deoxypyridinoline
- dexa scan
- dexamethasone suppression
- dexamethasone suppression (high dose)
- dexamethasone suppression (low dose)
- dhea sulphate
- discectomy
- dldl cholesterol
- dmsa scan
- dna sequencing
- domperidone
- down syndrome screening
- ductal lavage
- echocardiogram
- eeg
- electrocardiogram
- electrolytes
- electromyography
- endoscopic ultrasound
- endoscopy
- endosonography
- enzyme immunoassay
- epinephrine (plasma)
- epinephrine (urine)
- erythrocyte sedimentation rate
- estimated glomerular filtration rate
- ethanol ablation
- ewing and clarke autonomic function
- exercise tolerance
- fbc
- ferritin
- fine needle aspiration biopsy
- flow cytometry
- fludrocortisone suppression
- fluticasone-propionate-17-beta carboxylic acid
- fmri
- folate
- ft3
- ft4
- gada
- gallium nitrate
- gallium scan
- gastric biopsy
- genetic analysis
- genitography
- gh day curve
- gh stimulation
- gh suppression
- glp-1
- glp-2
- glucose suppression test
- glucose (blood)
- glucose (blood, fasting)
- glucose (blood, postprandial)
- glucose (urine)
- glucose tolerance
- glucose tolerance (intravenous)
- glucose tolerance (oral)
- glucose tolerance (prolonged)
- gluten sensitivity
- gnrh stimulation
- gonadotrophins
- growth hormone-releasing peptide-2 test
- gut hormones (fasting)
- haematoxylin and eosin staining
- haemoglobin
- haemoglobin a1c
- hcg (serum)
- hcg (urine)
- hcg stimulation
- hdl cholesterol
- hearing test
- heart rate
- hepatic venous sampling with arterial stimulation
- high-sensitivity c-reactive protein
- histopathology
- hla genotyping
- holter monitoring
- homa
- homocysteine
- hyaluronic acid
- hydrocortisone day curve
- hydroxyproline
- hydroxyprogesterone
- hysteroscopy
- igfbp2
- igfbp3
- igg4/igg ratio
- immunocytochemistry
- immunohistochemistry
- immunoglobulins
- immunoglobulin g2
- immunoglobulin g4
- immunoglobulin a
- immunoglobulin m
- immunostaining
- inferior petrosal sinus sampling
- inhibin b
- insulin (fasting)
- insulin suppression
- insulin tissue resistance tests
- insulin tolerance
- intracranial pressure
- irm imaging
- ketones (plasma)
- ketones (urine)
- kidney function
- lactate
- lactate dehydrogenase
- laparoscopy
- laparoscopy and dye
- laparotomy
- ldl cholesterol
- leuprolide acetate stimulation
- leukocyte esterase (urine)
- levothyroxine absorption
- lipase (serum)
- lipid profile
- liquid-based cytology
- liquid chromatography-mass spectrometry
- liver biopsy
- liver function
- lumbar puncture
- lung function testing
- luteinising hormone releasing hormone test
- macroprolactin
- magnesium
- mag3 scan
- mammogram
- mantoux test
- metanephrines (plasma)
- metanephrines (urinary)
- methoxytyramine
- metoclopramide
- metyrapone cortisol day curve
- metyrapone suppression
- metyrapone test dose
- mibg scan
- microarray analysis
- molecular genetic analysis
- mri
- myocardial biopsy
- nerve conduction study
- neuroendocrine markers
- neuron-specific enolase
- norepinephrine
- ntx
- oct
- octreotide scan
- octreotide suppression test
- osmolality
- ovarian venous sampling
- p1np
- palpation
- pap test
- parathyroid scintigraphy
- pentagastrin
- perchlorate discharge
- percutaneous umbilical blood sampling
- peripheral blood film
- pet scan
- ph (blood)
- phosphate (serum)
- phosphate (urine)
- pituitary function
- plasma osmolality
- plasma viscosity
- platelet count
- pneumococcal antigen
- pneumococcal pcr
- polymerase chain reaction
- polysomnography
- porter-silber chromogens
- potassium
- pregnancy test
- proinsulin
- prostate-specific antigen
- protein electrophoresis
- protein fingerprinting
- protein folding analysis
- psychiatric assessment
- psychometric assessment
- pulse oximetry
- pyelography
- pyridinium crosslinks
- quicki
- plasma renin activity
- radioimmunoassay
- radionuclide imaging
- raiu test
- red blood cell count
- renal biopsy
- renin (24-hour urine)
- respiratory status
- renin (blood)
- renin plasma activity
- rheumatoid factor
- salt loading
- sdldl cholesterol
- secretin stimulation
- selective parathyroid venous sampling
- selective transhepatic portal venous sampling
- semen analysis
- serotonin
- serum osmolality
- serum free insulin
- sestamibi scan
- sex hormone binding globulin
- shbg
- skeletal muscle mass
- skin biopsy
- sleep diary
- sodium
- spect scan
- supervised 72-hour fast
- surgical biopsy
- sweat test
- synaptophysin
- systemic vascular resistance index
- tanner scale
- thoracocentesis
- thyroid transcription factor-1
- thyroglobulin
- thyroid antibodies
- thyroid function
- thyroid scintigraphy
- thyroid ultrasonography
- total cholesterol
- total ghrelin
- total t3
- total t4
- trabecular thickness
- transaminase
- transvaginal ultrasound
- trap 5b
- trh stimulation
- triglycerides
- triiodothyronine (t3) suppression
- troponin
- tsh receptor antibodies
- type 3 precollagen
- type 4 collagen
- ultrasound-guided biopsy
- ultrasound scan
- urea and electrolytes
- uric acid (blood)
- uric acid (urine)
- urinalysis
- urinary free cortisol
- urine 24-hour volume
- urine osmolality
- vaginal examination
- vanillylmandelic acid (24-hour urine)
- visual field assessment
- vitamin b12
- vitamin e
- waist circumference
- water deprivation
- water load
- weight
- western blotting
- white blood cell count
- white blood cell differential count
- x-ray
- zinc
- abscess drainage
- acetic acid injection
- adhesiolysis
- adrenalectomy
- amputation
- analgesics
- angioplasty
- arthrodesis
- assisted reproduction techniques
- bariatric surgery
- bilateral salpingo-oophorectomy
- blood transfusion
- bone grafting
- caesarean section
- cardiac transplantation
- cardiac pacemaker
- cataract extraction
- chemoembolisation
- chemotherapy
- chemoradiotherapy
- clitoroplasty
- continuous renal replacement therapy
- contraception
- cordotomy
- counselling
- craniotomy
- cryopreservation
- cryosurgical ablation
- debridement
- dialysis
- diazoxide
- diet
- duodenotomy
- endonasal endoscopic surgery
- exercise
- external fixation
- extracorporeal shock wave lithotripsy
- extraocular muscle surgery
- eye surgery
- eyelid surgery
- fasciotomy
- fluid repletion
- fluid restriction
- gamma knife radiosurgery
- gastrectomy
- gastrostomy
- gender reassignment surgery
- gonadectomy
- heart transplantation
- hormone replacement
- hormone suppression
- hypophysectomy
- hysterectomy
- inguinal orchiectomy
- internal fixation
- intra-cardiac defibrillator
- islet transplantation
- ivf
- kidney transplantation
- laparoscopic adrenalectomy
- laryngoplasty
- laryngoscopy
- laser lithotripsy
- light treatment
- liver transplantation
- lumpectomy
- lymph node dissection
- mastectomy
- molecularly targeted therapy
- neuroendoscopic surgery
- oophorectomy
- orbital decompression
- orbital radiation
- orchidectomy
- orthopaedic surgery
- osteotomy
- ovarian cystectomy
- ovarian diathermy
- oxygen therapy
- pancreas transplantation
- pancreatectomy
- pancreaticoduodenectomy
- parathyroidectomy
- percutaneous adrenal ablation
- percutaneous nephrolithotomy
- pericardiocentesis
- pericardiotomy
- physiotherapy
- pituitary adenomectomy
- plasma exchange
- plasmapheresis
- psychotherapy
- radiofrequency ablation
- radionuclide therapy
- radiotherapy
- reconstruction of genitalia
- resection of tumour
- right-sided hemicolectomy
- salpingo-oophorectomy
- small bowel resection
- speech and language therapy
- spinal surgery
- splenectomy
- stereotactic radiosurgery
- termination of pregnancy
- thymic transplantation
- thyroidectomy
- tracheostomy
- transcranial surgery
- transsphenoidal surgery
- transtentorial surgery
- vaginoplasty
- vagotomy
- 5-alpha-reductase inhibitors
- 17?-estradiol
- abiraterone
- acarbose
- acetazolamide
- acetohexamide
- adalimumab
- albiglutide
- alendronate
- alogliptin
- alpha-blockers
- alphacalcidol
- alpha-glucosidase inhibitors
- amiloride
- amlodipine
- amoxicillin
- anastrozole
- angiotensin-converting enzyme inhibitors
- angiotensin receptor antagonists
- anthracyclines
- antiandrogens
- antibiotics
- antiemetics
- antiepileptics
- antipsychotics
- antithyroid drugs
- antiseptic
- antivirals
- aripiprazole
- aromatase inhibitors
- aspirin
- astragalus membranaceus
- ativan
- atenolol
- atorvastatin
- avp receptor antagonists
- axitinib
- azathioprine
- bendroflumethiazide
- benzodiazepines
- beta-blockers
- betamethasone
- bexlosteride
- bicalutamide
- bisphosphonates
- bleomycin
- botulinum toxin
- bromocriptine
- cabergoline
- cabozantinib
- calcimimetics
- calcitonin (salmon)
- calcium
- calcium carbonate
- calcium chloride
- calcium dobesilate
- calcium edta
- calcium gluconate
- calcium-l-aspartate
- calcium polystyrene sulphonate
- canagliflozin
- capecitabine
- captopril
- carbimazole
- carboplatin
- carbutamide
- carvedilol
- ceftriaxone
- chlorothiazide
- chlorpropamide
- cholecalciferol
- cholinesterase inhibitors
- ciclosporin
- cinacalcet
- cisplatin
- clodronate
- clomifene
- clomiphene citrate
- clopidogrel
- co-cyprindiol
- codeine
- colonic polyps
- combined oral contraceptive pill
- conivaptan
- cortisone acetate
- continuous subcutaneous hydrocortisone infusion
- continuous subcutaneous insulin infusion
- coumadin
- corticosteroids
- cortisol
- cyproterone acetate
- dacarbazine
- danazol
- dapagliflozin
- daunorubicin
- deferiprone
- demeclocycline
- denosumab
- desmopressin
- dexamethasone
- diazepam
- diethylstilbestrol
- digoxin
- diltiazem
- diphenhydramine
- diuretics
- docetaxel
- dopamine agonists
- dopamine antagonists
- dopamine receptor agonists
- doxazosin
- doxepin
- doxorubicin
- dpp4 inhibitors
- dutasteride
- dutogliptin
- eflornithine
- enoxaparin
- empagliflozin
- epinephrine
- epirubicin
- eplerenone
- epristeride
- equilenin
- equilin
- erlotinib
- ethinylestradiol
- etidronate
- etomidate
- etoposide
- everolimus
- exenatide
- fenofibrate
- finasteride
- fluconazole
- fluticasone
- fludrocortisone
- fluorouracil
- fluoxetine
- flutamide
- furosemide
- gaba receptor antagonists
- gefitinib
- gemcitabine
- gemigliptin
- ginkgo biloba
- glibenclamide
- glibornuride
- gliclazide
- glimepiride
- glipizide
- gliquidone
- glisoxepide
- glp1 agonists
- glucose
- glyclopyramide
- gnrh analogue
- gnrh antagonists
- heparin
- hrt (menopause)
- hydrochlorothiazide
- hydrocortisone
- ibandronate
- ibuprofen
- idarubicin
- idebenone
- imatinib
- immunoglobulin therapy
- implanon
- indapamide
- infliximab
- iron supplements
- isoniazid
- insulin aspart
- insulin glargine
- insulin glulisine
- insulin lispro
- interferon
- intrauterine system
- iopanoic acid
- ipilimumab
- ipragliflozin
- irbesartan
- izonsteride
- ketoconazole
- labetalol
- lactulose
- lanreotide
- leuprolide acetate
- levatinib
- levodopa
- levonorgestrel
- levothyroxine
- linagliptin
- liothyronine
- liraglutide
- lithium
- lisinopril
- lixivaptan
- loperamide
- loprazolam
- lormetazepam
- losartan
- low calcium formula
- magnesium glycerophosphate
- magnesium sulphate
- mecasermin
- medronate
- medroxyprogesterone acetate
- meglitinides
- menotropin
- metformin
- methadone
- methimazole
- methylprednisolone
- metoprolol
- metyrapone
- miglitol
- mitotane
- mitoxantrone
- mozavaptan
- mtor inhibitors
- multivitamins
- naproxen
- natalizumab
- nateglinide
- nelivaptan
- neridronate
- nifedipine
- nilutamide
- nitrazepam
- nivolumab
- nsaid
- octreotide
- oestradiol valerate
- olanzapine
- olpadronate
- omeprazole
- opioids
- oral contraceptives
- orlistat
- ornipressin
- otelixizumab
- oxandrolone
- oxidronate
- oxybutynin
- paclitaxel
- pamidronate
- pancreatic enzymes
- pantoprazole
- paracetamol
- paroxetine
- pasireotide
- pegvisomant
- perindopril
- phenobarbital
- phenoxybenzamine
- phosphate binders
- phosphate supplements
- phytohaemagglutinin induced interferon gamma
- pioglitazone
- plicamycin
- potassium chloride
- potassium iodide
- pramlintide
- prazosin
- prednisolone
- prednisone
- premarin
- promethazine
- propranolol
- propylthiouracil
- protease inhibitors
- proton pump inhibitors
- pyridostigmine
- quetiapine
- quinagolide
- quinestrol
- radioactive mibg
- radioactive octreotide
- radioiodine
- raloxifene
- ramipril
- relcovaptan
- remogliflozin etabonate
- repaglinide
- risperidone
- risedronate
- rituximab
- romidepsin
- rosiglitazone
- salbutamol
- saline
- salmeterol
- salt supplements
- satavaptan
- saxagliptin
- selective progesterone receptor modulators
- selenium
- sglt2 inhibitors
- sildenafil
- simvastatin
- sirolimus
- sitagliptin
- sodium bicarbonate
- sodium chloride
- sodium polystyrene sulfonate (kayexalate)
- somatostatin analogues
- sorafenib
- spironolactone
- ssris
- statins
- streptozotocin
- steroids
- strontium ranelate
- sucralfate
- sulphonylureas
- sunitinib
- tamoxifen
- taspoglutide
- temazepam
- temozolomide
- teplizumab
- terazosin
- teriparatide
- testolactone
- testosterone enanthate esters
- tetrabenazine
- thalidomide
- thiazolidinediones
- thyrotropin alpha
- tibolone
- tiludronate
- tiratricol (triac)
- tofogliflozin
- tolazamide
- tolbutamide
- tolvaptan
- tramadol
- trastuzumab
- trazodone
- triamcinolone
- triamterene
- trimipramine
- troglitazone
- tryptophan
- turosteride
- tyrosine-kinase inhibitors
- valproic acid
- valrubicin
- vandetanib
- vaptans
- vildagliptin
- vinorelbine
- voglibose
- vorinostat
- warfarin
- zaleplon
- z-drugs
- zoledronic acid
- zolpidem
- zopiclone
- cardiology
- dermatology
- gastroenterology
- general practice
- genetics
- geriatrics
- gynaecology
- nephrology
- neurology
- nursing
- obstetrics
- oncology
- otolaryngology
- paediatrics
- pathology
- podiatry
- psychology/psychiatry
- radiology/rheumatology
- rehabilitation
- surgery
- urology
- insight into disease pathogenesis or mechanism of therapy
- novel diagnostic procedure
- novel treatment
- unique/unexpected symptoms or presentations of a disease
- new disease or syndrome: presentations/diagnosis/management
- unusual effects of medical treatment
- error in diagnosis/pitfalls and caveats
- february
- 2022
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Affiliation(s)
- Aria Jazdarehee
- Department of Medicine and Faculty of Medicine, University of British Columbia, British Columbia, Canada
| | - Sawyer Huget-Penner
- Division of Endocrinology and Metabolism, Fraser Health Authority, British Columbia, Canada
| | - Monika Pawlowska
- Division of Endocrinology and Metabolism, University of British Columbia, British Columbia, Canada
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18
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Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in pregnancy may have devastating complications including fetal demise. Here, we describe a case of SARS-CoV-2 infection in a second-trimester pregnancy. The placenta demonstrated the presence of SARS-CoV-2 viral RNA along with intervillositis and perivillous fibrin deposition. SARS-CoV-2 directly infects the trophoblastic cells of the placenta through the angiotensin-converting enzyme 2 receptor. This case report details the clinical history of a SARS-CoV-2-infected pregnancy with fetal demise. In addition, we show the images of the placental pathology and SARS-CoV-2 RNA in situ studies.
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Affiliation(s)
- Dominic J Bewley
- Pathology, Burrell College of Osteopathic Medicine, Las Cruces, USA
| | - Jessica Lee
- Pathology, Burrell College of Osteopathic Medicine, Las Cruces, USA
| | - Oana Popescu
- Pathology and Laboratory Medicine, Vernon Jubilee Hospital, Vernon, CAN
| | - Angelica Oviedo
- Pathology and Laboratory Medicine, Burrell College of Osteopathic Medicine, Las Cruces, USA
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19
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Thomas J, Sun Y, Debelenko L. Infrequent Placental and Fetal Involvement in SARS-CoV-2 Infection: Pathology Data from a Large Medical Center. J Dev Biol 2021; 9:jdb9040045. [PMID: 34698210 PMCID: PMC8544396 DOI: 10.3390/jdb9040045] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 09/28/2021] [Accepted: 10/14/2021] [Indexed: 12/14/2022] Open
Abstract
In order to determine the frequency of SARS-CoV-2 placental and fetal involvements, we analyzed placentas of 197 women positive for infection at delivery and fetal tissues in cases of pregnancy loss in women positive by SARS-CoV-2 PCR (N = 2) and COVID-19 serology (N = 4), using in situ hybridization (ISH), immunohistochemistry (IHC) and, in selected cases, RT-PCR of tissue homogenates. The virus was identified in situ, accompanied by intervillositis, in 2 of 197 placentas (1.02%). In three more cases, SARS-CoV-2 was detected by tissue PCR without in situ localization and placental inflammation. There were no maternal mortality or association of placental infection with the clinical severity of COVID-19. All tested neonates born to SARS-CoV-2-positive women (N = 172) were negative for the virus. There were three pregnancy losses among 197 infected women and in two cases available fetal tissues were negative for SARS-CoV-2. In one of four fetal autopsies performed in women with positive COVID-19 serology, the mother-to-child transmission (MTCT) could be inferred based on positive SARS-CoV-2 nucleocapsid IHC in fetal pulmonary endothelium. Placental involvement by SARS-CoV-2 is rare, but may be underestimated due to its transient nature. MTCT is even rarer, supporting the protective role of placenta in SARS-CoV-2 infection.
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20
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Tasneem B, Fox D, Akhter S. Blunt Abdominal Trauma in the Third Trimester: Eight Departments, Two Patients, One Survivor. Cureus 2021; 13:e16688. [PMID: 34466321 PMCID: PMC8395372 DOI: 10.7759/cureus.16688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/28/2021] [Indexed: 11/05/2022] Open
Abstract
Blunt abdominal trauma is one of the leading causes of non-obstetrics-related deaths during pregnancy, with motor vehicle collision, falls, and assaults being the most common etiologies. While a trauma team plays a central role in the care of a pregnant trauma patient, a multidisciplinary involvement is vital to ensure the safety of the fetus and the mother. This case study will follow the step-by-step multidisciplinary approach utilized for a 37-year-old female in her third trimester who suffered blunt trauma and arrived at a Level 1 trauma center that led to maternal survival but fetal demise. She was initially evaluated by Emergency Medicine and Obstetrics/Gynecology departments for maternal and fetal trauma, by Orthopedics for several fractures including the pubic ramus and sacral ala fractures, as well as by Neurosurgery for a subarachnoid hemorrhage and a subdural hematoma. Subsequently, the following departments were brought on after the patient suddenly became hypotensive with abdominal tenderness to assess for internal bleeding: Interventional Radiology, Trauma, Surgery, and Urology. Retroperitoneal and pelvic hematomas were found to be the source of bleeding during an emergency laparotomy and the decision was made for an emergency caesarian section. The neonatal intensive care unit ultimately could not start the fetal heart. In the days that followed, the neurosurgery department monitored the worsening intercranial bleeds while Psychiatry and Social Work attended to the patient. A proper systematic approach towards a patient in this situation necessitates expertise from multiple fields, and the success of this interplay greatly affects patient outcomes.
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Affiliation(s)
- Bilal Tasneem
- Emergency Medicine, Richmond University Medical Center, Staten Island, USA
| | - Daniel Fox
- Emergency Medicine, Richmond University Medical Center, Staten Island, USA
| | - Shahnaz Akhter
- Research, Richmond University Medical Center, Staten Island, USA
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21
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Abstract
Bacillus cereus is a gram-positive, rod-shaped bacterium that is commonly implicated in foodborne illness but has also become increasingly recognized as a source of serious non-gastrointestinal infections, including sepsis, meningitis, and pneumonia. Non-gastrointestinal B. cereus infections have been identified in children, especially in neonates; however, there are no previously described cases of fetal demise associated with B. cereus placental infection. We present a case of acute chorioamnionitis-related intrauterine fetal demise of twin A at 17 weeks gestation, noted two days after selective termination of twin B. Histological examination revealed numerous gram-positive bacilli in placental tissue, as well as fetal vasculature, in the setting of severe acute necrotizing chorioamnionitis and subchorionitis, intervillous abscesses, acute villitis, and peripheral acute funisitis. Cultures of maternal blood and placental tissue both yielded growth of B. cereus. This case underscores the importance of B. cereus as a human pathogen, and specifically demonstrates its potential as an agent of severe intraamniotic and placental infection with poor outcomes for the fetus.
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Affiliation(s)
- Stephanie Shea
- Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Emilia Sordillo
- Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Michael Nowak
- Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Fumiko Dekio
- Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, New York
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22
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Panaitescu AM, Gică N, Botezatu R, Cimpoca B, Veduță A, Peltecu G, Ciobanu AM. Early Ultrasound Identification of Cord Entanglement in Monochorionic Monoamniotic Twin Pregnancy. Diagnostics (Basel) 2021; 11:diagnostics11030520. [PMID: 33804073 PMCID: PMC8000087 DOI: 10.3390/diagnostics11030520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 03/06/2021] [Accepted: 03/09/2021] [Indexed: 12/02/2022] Open
Abstract
Monochorionic monoamniotic pregnancy are considered high risk gestations and the fetal outcome is at times unpredictable. Correct diagnosis and counselling are extremely important, especially regarding the risk of unexpected fetal demise. We present the rare case of a monochorionic monoamniotic twin pregnancy with early identification of cord entanglement and the characteristic ultrasound findings in the first trimester of pregnancy.
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Affiliation(s)
- Anca Maria Panaitescu
- “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (N.G.); (R.B.); (G.P.)
- Department of Obstetrics and Gynecology, Filantropia Clinical Hospital, 011171 Bucharest, Romania; (B.C.); (A.V.); (A.M.C.)
- Correspondence:
| | - Nicolae Gică
- “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (N.G.); (R.B.); (G.P.)
- Department of Obstetrics and Gynecology, Filantropia Clinical Hospital, 011171 Bucharest, Romania; (B.C.); (A.V.); (A.M.C.)
| | - Radu Botezatu
- “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (N.G.); (R.B.); (G.P.)
- Department of Obstetrics and Gynecology, Filantropia Clinical Hospital, 011171 Bucharest, Romania; (B.C.); (A.V.); (A.M.C.)
| | - Brîndușa Cimpoca
- Department of Obstetrics and Gynecology, Filantropia Clinical Hospital, 011171 Bucharest, Romania; (B.C.); (A.V.); (A.M.C.)
| | - Alina Veduță
- Department of Obstetrics and Gynecology, Filantropia Clinical Hospital, 011171 Bucharest, Romania; (B.C.); (A.V.); (A.M.C.)
| | - Gheorghe Peltecu
- “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (N.G.); (R.B.); (G.P.)
- Department of Obstetrics and Gynecology, Filantropia Clinical Hospital, 011171 Bucharest, Romania; (B.C.); (A.V.); (A.M.C.)
| | - Anca Marina Ciobanu
- Department of Obstetrics and Gynecology, Filantropia Clinical Hospital, 011171 Bucharest, Romania; (B.C.); (A.V.); (A.M.C.)
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23
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Abstract
OBJECTIVES To provide an investigation protocol to help health care providers determine the cause of a fetal death. OPTIONS Consideration has been given to protocols for the investigation of fetal death that are currently available in Canada and in other countries. OUTCOMES Identification of possible causes of stillbirth and their relationship to future pregnancies. EVIDENCE Articles related to the etiology of fetal death were identified in a search of PubMed (June 2006 to September 2018), the Cochrane Library, and investigation protocols from the American College of Obstetricians and Gynecologists, the International Stillbirth Alliance Collaborative for Improving Classification of Perinatal Deaths, the Royal College of Obstetricians and Gynaecologists, the Queensland clinical guidelines, and the Reproductive Care Program of Nova Scotia. BENEFITS To provide better advice for women regarding possible causes of fetal death and implications for future pregnancies. VALIDATION The evidence obtained was reviewed and evaluated by the Maternal-Fetal Medicine Committee and the Clinical Practice Obstetrics Committee of the Society of Obstetricians and Gynaecologists of Canada. The level of evidence and quality of the recommendation made was described using the Evaluation of Evidence criteria of the Canadian Task Force on Preventive Health Care. RECOMMENDATIONS
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24
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Kodera C, Aoki S, Ohba T, Higashimoto K, Mikami Y, Fukunaga M, Soejima H, Katabuchi H. Clinical manifestations of placental mesenchymal dysplasia in Japan: A multicenter case series. J Obstet Gynaecol Res 2021; 47:1118-1125. [PMID: 33462953 DOI: 10.1111/jog.14647] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 12/15/2020] [Accepted: 12/22/2020] [Indexed: 01/13/2023]
Abstract
AIM This study aimed to evaluate the clinical features and pregnancy outcomes of placental mesenchymal dysplasia (PMD) in Japan. METHODS We requested detailed clinical information and placental tissue of PMD cases in 2000-2018 from Japanese facilities with departments of obstetrics and gynecology and analyzed the pregnancy course and neonatal outcomes. RESULTS We collected 49 cases of PMD. Of 18 patients with measured maternal serum alpha-fetoprotein (MSAFP) levels, 15 (83.3%) had elevated levels. Maternal serum human chorionic gonadotropin (MShCG) levels were transiently elevated in five (17.8%) of 28 patients. Forty-seven patients continued their pregnancies. All pregnancies were singleton and 40 (85.1%) were associated with adverse events including fetal growth restriction (FGR), threatened premature delivery, fetal demise, and hypertensive disorder of pregnancy in 34 (72.3%), 14 (29.8%), eight (17.0%), and six (12.8%) patients, respectively. Of 47 infants, there were eight stillbirths. There were 40 (85.1%) female infants, and eight (17.0%) had Beckwith-Wiedemann syndrome. Of 39 live births, 23 (59.0%) were associated with premature induction of labor or cesarean section for obstetric indications related to FGR. Eighteen (46.2%) neonates had complications. PMD-affected placentas were pathologically heterogeneous in both grossly PMD-affected and non-affected areas. CONCLUSIONS Our study included the largest number of PMD cases with detailed clinical information. PMD is a high-risk condition for both the mother and the child. Elevated MSAFP levels with normal MShCG levels indicate PMD. Conventional perinatal management of FGR in Japan might be effective in reducing the fetal mortality rate.
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Affiliation(s)
- Chisato Kodera
- Department of Obstetrics and Gynecology, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Saori Aoki
- Division of Molecular Genetics and Epigenetics, Department of Biomolecular Sciences, Faculty of Medicine, Saga University, Saga, Japan
| | - Takashi Ohba
- Department of Obstetrics and Gynecology, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Ken Higashimoto
- Division of Molecular Genetics and Epigenetics, Department of Biomolecular Sciences, Faculty of Medicine, Saga University, Saga, Japan
| | - Yoshiki Mikami
- Department of Diagnostic Pathology, Kumamoto University Hospital, Kumamoto, Japan
| | - Masaharu Fukunaga
- Department of Pathology, Shin-Yurigaoka General Hospital, Kawasaki, Japan
| | - Hidenobu Soejima
- Division of Molecular Genetics and Epigenetics, Department of Biomolecular Sciences, Faculty of Medicine, Saga University, Saga, Japan
| | - Hidetaka Katabuchi
- Department of Obstetrics and Gynecology, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
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25
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Koo SC, Bu F. Intraplacental Leiomyoma in a Case of Second-Trimester Intrauterine Fetal Demise. Clin Pathol 2020; 13:2632010X20928328. [PMID: 32596665 PMCID: PMC7297480 DOI: 10.1177/2632010x20928328] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 04/30/2020] [Indexed: 11/26/2022]
Abstract
Intraplacental leiomyomas are extremely rare and are generally incidental findings in term placentas. We present the first reported case of a placental leiomyoma associated with preterm intrauterine fetal demise, with histological findings providing the cause of adverse outcome. This was an intrauterine fetal demise detected at 26 weeks gestation with a placental finding of a 2.8-cm leiomyoma. Histological findings in the placenta and fetus were consistent with intrauterine fetal demise of weeks. The umbilical cord was markedly hypercoiled, with 6 twists per 10 cm. Features of maternal vascular malperfusion were evident in the placenta, including villous hypermaturity, an infarct adjacent to the leiomyoma, and retention of smooth muscle in spiral arterioles within the decidua overlying the leiomyoma. Implantation-site trophoblasts invaded into the leiomyoma and the overlying decidua. We hypothesize that incorporation of the leiomyoma into the placenta contributed to fetal demise due to disordered placental implantation, implying that these tumors may not be as benign and incidental as previously described. The finding of implantation-site changes in the leiomyoma may also suggest a potential cause for this rare tumor.
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Affiliation(s)
- Selene C Koo
- Department of Pathology and Laboratory Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pathology, The Ohio State University, Columbus, OH, USA
| | - Fang Bu
- Department of Pathology and Laboratory Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pathology, The Ohio State University, Columbus, OH, USA
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26
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Tollenaar LS, Lopriore E, Faiola S, Lanna M, Stirnemann J, Ville Y, Lewi L, Devlieger R, Weingertner AS, Favre R, Hobson SR, Ryan G, Rodo C, Arévalo S, Klaritsch P, Greimel P, Hecher K, de Sousa MT, Khalil A, Thilaganathan B, Bergh EP, Papanna R, Gardener GJ, Carlin A, Bevilacqua E, Sakalo VA, Kostyukov KV, Bahtiyar MO, Wilpers A, Kilby MD, Tiblad E, Oepkes D, Middeldorp JM, Haak MC, Klumper FJ, Akkermans J, Slaghekke F. Post-Laser Twin Anemia Polycythemia Sequence: Diagnosis, Management, and Outcome in an International Cohort of 164 Cases. J Clin Med 2020; 9:E1759. [PMID: 32517071 PMCID: PMC7355738 DOI: 10.3390/jcm9061759] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 05/19/2020] [Accepted: 05/25/2020] [Indexed: 02/02/2023] Open
Abstract
The aim of this study was to investigate the management and outcome in the post-laser twin anemia polycythemia sequence (TAPS). Data of the international TAPS Registry, collected between 2014 and 2019, were used for this study. The primary outcomes were perinatal mortality and severe neonatal morbidity. Secondary outcomes included a risk factor analysis for perinatal mortality and severe neonatal morbidity. A total of 164 post-laser TAPS pregnancies were included, of which 92% (151/164) were diagnosed antenatally and 8% (13/164) postnatally. The median number of days between laser for TTTS and detection of TAPS was 14 (IQR: 7-28, range: 1-119). Antenatal management included expectant management in 43% (62/151), intrauterine transfusion with or without partial exchange transfusion in 29% (44/151), repeated laser surgery in 15% (24/151), selective feticide in 7% (11/151), delivery in 6% (9/151), and termination of pregnancy in 1% (1/151). The median gestational age (GA) at birth was 31.7 weeks (IQR: 28.6-33.7; range: 19.0-41.3). The perinatal mortality rate was 25% (83/327) for the total group, 37% (61/164) for donors, and 14% (22/163) for recipients (p < 0.001). Severe neonatal morbidity was detected in 40% (105/263) of the cohort and was similar for donors (43%; 51/118) and recipients (37%; 54/145), p = 0.568. Independent risk factors for spontaneous perinatal mortality were antenatal TAPS Stage 4 (OR = 3.4, 95%CI 1.4-26.0, p = 0.015), TAPS donor status (OR = 4.2, 95%CI 2.1-8.3, p < 0.001), and GA at birth (OR = 0.8, 95%CI 0.7-0.9, p = 0.001). Severe neonatal morbidity was significantly associated with GA at birth (OR = 1.5, 95%CI 1.3-1.7, p < 0.001). In conclusion, post-laser TAPS most often occurs within one month after laser for TTTS, but may develop up to 17 weeks after initial surgery. Management is mostly expectant, but varies greatly, highlighting the lack of consensus on the optimal treatment and heterogeneity of the condition. Perinatal outcome is poor, particularly due to the high rate of perinatal mortality in donor twins.
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Affiliation(s)
- Lisanne S.A. Tollenaar
- Department of Obstetrics, Division of Fetal therapy, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (D.O.); (J.M.M.); (M.C.H.); (F.J.C.M.K.); (J.A.); (F.S.)
| | - Enrico Lopriore
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands;
| | - Stefano Faiola
- Fetal Therapy Unit “U. Nicolini”, Vittore Buzzi Children’s Hospital, University of Milan, 20154 Milan, Italy; (S.F.); (M.L.)
| | - Mariano Lanna
- Fetal Therapy Unit “U. Nicolini”, Vittore Buzzi Children’s Hospital, University of Milan, 20154 Milan, Italy; (S.F.); (M.L.)
| | - Julien Stirnemann
- Department of Obstetrics and Maternal-Fetal Medicine, Hôpital Necker Enfants Malades, AP-HP, 75015 Paris, France; (J.S.); (Y.V.)
| | - Yves Ville
- Department of Obstetrics and Maternal-Fetal Medicine, Hôpital Necker Enfants Malades, AP-HP, 75015 Paris, France; (J.S.); (Y.V.)
| | - Liesbeth Lewi
- Department of Obstetrics and Gynecology, University Hospitals Leuven, 3000 Leuven, Belgium; (L.L.); (R.D.)
| | - Roland Devlieger
- Department of Obstetrics and Gynecology, University Hospitals Leuven, 3000 Leuven, Belgium; (L.L.); (R.D.)
| | - Anne Sophie Weingertner
- Department of Obstetrics and Gynecology, Strasbourg University Hospital, CEDEX, 67000 Strasbourg, France; (A.S.W.); (R.F.)
| | - Romain Favre
- Department of Obstetrics and Gynecology, Strasbourg University Hospital, CEDEX, 67000 Strasbourg, France; (A.S.W.); (R.F.)
| | - Sebastian R. Hobson
- Fetal Medicine Unit, Department of Obstetrics & Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, ON M5G 1X5, Canada; (S.R.H.); (G.R.)
| | - Greg Ryan
- Fetal Medicine Unit, Department of Obstetrics & Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, ON M5G 1X5, Canada; (S.R.H.); (G.R.)
| | - Carlota Rodo
- Maternal Fetal Medicine Unit, Department of Obstetrics, Vall d’Hebron University Hospital, 08035 Barcelona, Spain; (C.R.); (S.A.)
| | - Silvia Arévalo
- Maternal Fetal Medicine Unit, Department of Obstetrics, Vall d’Hebron University Hospital, 08035 Barcelona, Spain; (C.R.); (S.A.)
| | - Philipp Klaritsch
- Division of Obstetrics and Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Medical University of Graz, 8036 Graz, Austria; (P.K.); (P.G.)
| | - Patrick Greimel
- Division of Obstetrics and Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Medical University of Graz, 8036 Graz, Austria; (P.K.); (P.G.)
| | - Kurt Hecher
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany; (K.H.); (M.T.d.S.)
| | - Manuela Tavares de Sousa
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany; (K.H.); (M.T.d.S.)
| | - Asma Khalil
- Fetal Medicine Unit, St George University Hospital NHS Foundation Trust, London SW17 0RE, UK; (A.K.); (B.T.)
| | - Basky Thilaganathan
- Fetal Medicine Unit, St George University Hospital NHS Foundation Trust, London SW17 0RE, UK; (A.K.); (B.T.)
| | - Eric P. Bergh
- The Fetal Center, Department of Obstetrics, Children’s Memorial Hermann Hospital, Gynecology and Reproductive Sciences, UT Health, McGovern Medical School, University of Texas, Houston, TX 77030, USA; (E.P.B.); (R.P.)
| | - Ramesha Papanna
- The Fetal Center, Department of Obstetrics, Children’s Memorial Hermann Hospital, Gynecology and Reproductive Sciences, UT Health, McGovern Medical School, University of Texas, Houston, TX 77030, USA; (E.P.B.); (R.P.)
| | - Glenn J. Gardener
- Department of Maternal Fetal Medicine, Mater Mothers’ Hospital, South Brisbane, QLD 4101, Australia;
| | - Andrew Carlin
- Department of Obstetrics and Gynecology, University Hospital Brugmann, Université Libre de Bruxelles, 1020 Brussels, Belgium; (A.C.); (E.B.)
| | - Elisa Bevilacqua
- Department of Obstetrics and Gynecology, University Hospital Brugmann, Université Libre de Bruxelles, 1020 Brussels, Belgium; (A.C.); (E.B.)
| | - Victorya A. Sakalo
- Acad. V.I. Kulakov Research Center of Obstetrics, Gynecology, and Perinatology, Ministry of Health of the Russian Federation, 495 Moscow, Russia; (V.A.S.); (K.V.K.)
| | - Kirill V. Kostyukov
- Acad. V.I. Kulakov Research Center of Obstetrics, Gynecology, and Perinatology, Ministry of Health of the Russian Federation, 495 Moscow, Russia; (V.A.S.); (K.V.K.)
| | - Mert O. Bahtiyar
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT 06510, USA; (M.O.B.); (A.W.)
| | - Abigail Wilpers
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT 06510, USA; (M.O.B.); (A.W.)
| | - Mark D. Kilby
- Fetal Medicine Centre, Birmingham Women’s and Children’s Foundation Trust, University of Birmingham, Birmingham B4 6NH, UK;
| | - Eleonor Tiblad
- Center for Fetal Medicine, Karolinska University Hospital, 171 76 Stockholm, Sweden;
| | - Dick Oepkes
- Department of Obstetrics, Division of Fetal therapy, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (D.O.); (J.M.M.); (M.C.H.); (F.J.C.M.K.); (J.A.); (F.S.)
| | - Johanna M. Middeldorp
- Department of Obstetrics, Division of Fetal therapy, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (D.O.); (J.M.M.); (M.C.H.); (F.J.C.M.K.); (J.A.); (F.S.)
| | - Monique C. Haak
- Department of Obstetrics, Division of Fetal therapy, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (D.O.); (J.M.M.); (M.C.H.); (F.J.C.M.K.); (J.A.); (F.S.)
| | - Frans J.C.M. Klumper
- Department of Obstetrics, Division of Fetal therapy, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (D.O.); (J.M.M.); (M.C.H.); (F.J.C.M.K.); (J.A.); (F.S.)
| | - Joost Akkermans
- Department of Obstetrics, Division of Fetal therapy, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (D.O.); (J.M.M.); (M.C.H.); (F.J.C.M.K.); (J.A.); (F.S.)
| | - Femke Slaghekke
- Department of Obstetrics, Division of Fetal therapy, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (D.O.); (J.M.M.); (M.C.H.); (F.J.C.M.K.); (J.A.); (F.S.)
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27
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Salihu HM, Dongarwar D, King LM, Yusuf KK, Ibrahimi S, Salinas-Miranda AA. Phenotypes of fetal macrosomia and risk of stillbirth among term deliveries over the previous four decades. Birth 2020; 47:202-210. [PMID: 31925852 DOI: 10.1111/birt.12479] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 12/11/2019] [Accepted: 12/19/2019] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To evaluate the association between macrosomia and stillbirth over the previous four decades and to determine the consistency of the relationship. METHODS This was a population-based retrospective cohort study using United States Natality and Fetal Death Data from 1982 to 2017 and restricted to the gestational age range of 37-41 weeks inclusive. Macrosomia was defined as birthweight ≥4000 g and subdivided into its grades as previously recommended: grade 1 (4000-4499 g), grade 2 (4500-4999 g), and grade 3 (≥5000 g). We calculated temporal trends of stillbirth among fetuses with macrosomia over the years using joinpoint regression. We generated odds ratios from adjusted binomial logistic regression models to examine the association between macrosomia and risk of stillbirth stratified by grades using normal-weight infants (2500-3999 g) as referent. RESULTS Within the fetal macrosomia group, the rate of stillbirth declined from 2.04/1000 in 1982 to 1.05/1000 by the end of the study period (2017), representing a drop of about 48.5%. For the normal-weight fetuses, stillbirth rate declined from 1.95/1000 to 0.83/1000, equivalent to a decline of 57.4%. Macrosomia was significantly associated with elevated risk for stillbirth: grade 2 (OR = 1.27; 95% CI = 1.22-1.32) and grade 3 (OR = 5.97; 95% CI = 5.69-6.22). CONCLUSIONS Fetal macrosomia is a significant risk factor for fetal demise with the worst intrauterine survival observed among those classified as grade 3. Fetal macrosomia is a heterogeneous rather than a homogeneous entity in terms of risk profiles, and this needs to be considered in future policy guidelines.
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Affiliation(s)
- Hamisu M Salihu
- Center of Excellence in Health Equity, Training and Research, Baylor College of Medicine, Houston, TX, USA.,Family and Community Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Deepa Dongarwar
- Center of Excellence in Health Equity, Training and Research, Baylor College of Medicine, Houston, TX, USA.,Office of the Provost, Baylor College of Medicine, Houston, TX, USA
| | - Lindsey M King
- Family and Community Medicine, Baylor College of Medicine, Houston, TX, USA.,Department of Health Services Research, Management and Policy, College of Public Health & Health Professions, University of Florida, Gainesville, FL, USA.,College of Public Health, University of South Florida, Tampa, FL, USA
| | - Korede K Yusuf
- College of Nursing & Public Health, Adelphi University, Garden City, NY, USA
| | - Sahra Ibrahimi
- College of Nursing & Public Health, Adelphi University, Garden City, NY, USA
| | - Abraham A Salinas-Miranda
- Center of Excellence in Maternal and Child Health Education, Science, and Practice, College of Public Health, University of South Florida, Tampa, FL, USA
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28
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Abstract
Morganella morganii is a rare opportunistic pathogen that is known to cause urinary tract and intra-abdominal infections. Per our literature review, there are few case reports of neonatal sepsis associated with this organism but to our knowledge, there are no case reports of Morganella morganii causing fetal demise in published literature in the Englishlanguage. In this case report, we present a case of a 34-year-old pregnant woman who had a hospital course complicated by Morganella morganii, which eventually led to stillbirth.
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Affiliation(s)
- Sofanit A Dessie
- Internal Medicine, Marshall University, Joan C. Edwards School of Medicine, Huntington, USA
| | - Varun Dobariya
- Internal Medicine, Marshall University, Joan C. Edwards School of Medicine, Huntington, USA
| | - Davinder Singh
- Internal Medicine, Marshall University, Joan C. Edwards School of Medicine, Huntington, USA
| | - Peimei He
- Internal Medicine, Marshall University, Huntington, USA
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29
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Jacques SM, Qureshi F. Do Increased Intra-alveolar Squamous Cells at Autopsy Correlate With Acute Fetal Asphyxia? Pediatr Dev Pathol 2020; 23:139-143. [PMID: 31461388 DOI: 10.1177/1093526619872617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
It is a generally held concept that finding increased aspirated amniotic fluid squames at autopsy supports a diagnosis of acute fetal asphyxia, the massive aspiration of squames being an indicator of terminal gasping. To evaluate this concept, we identified autopsies on 15 third-trimester stillborns with clinical acute placental abruption (acute asphyxia); 13 also had thymic petechiae and none had severe acute thymic involution, findings also supporting acute asphyxia. Thirty third-trimester stillborns with findings supporting a subacute or chronic mode of death, including severe thymic involution and absence of thymic petechiae, comprised the comparison group. Intra-alveolar squames were scored as 0, no squames; 1+, scattered squames singly or in small groups; and 2+, squames in many alveoli, at least focally in compacted clusters. In all cases, the squames were patchily distributed, and none received a score of 0. In the abruption group, the intra-alveolar squames were scored as 1+ in 12 (80%) and as 2+ in 3 (20%) cases, while in the comparison group, the squames were scored as 1+ in 20 (67%) and 2+ in 10 (33%) cases (P = NS). There was also no difference in the quantification of intra-alveolar squames in term compared to preterm stillborns. In conclusion, quantification of intra-alveolar squames did not aid in separating an acute mode of death (acute asphyxia) from subacute or chronic modes of death.
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Affiliation(s)
- Suzanne M Jacques
- Department of Pathology, Detroit Medical Center and Wayne State University School of Medicine, Hutzel Women's Hospital, Detroit, Michigan
| | - Faisal Qureshi
- Department of Pathology, Detroit Medical Center and Wayne State University School of Medicine, Hutzel Women's Hospital, Detroit, Michigan
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Duncan JR, Dorsett KM, Vilchez G, Schenone MH, Mari G. Uterine artery pulsatility index for the prediction of obstetrical complications in preterm prelabor rupture of membranes. J Matern Fetal Neonatal Med 2019; 34:4060-4063. [PMID: 31842648 DOI: 10.1080/14767058.2019.1702961] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: Abnormal uterine artery Doppler studies have been associated with an increased risk of preeclampsia, fetal growth restriction (FGR), placental abruption, and fetal demise. These obstetrical complications can affect pregnancies with preterm prelabor rupture of membranes (PPROM). Therefore, our objective was to assess the prediction accuracy of the uterine artery pulsatility index (UtAPI) to detect these complications in pregnancies with PPROM.Materials and methods: This was a prospective study of pregnancies complicated by PPROM from October 2015 to May 2018. We included mothers aged 13-46 years old with singleton pregnancies from 23 to 36 + 6 weeks with PPROM. Those without UtAPI measurements and complex fetal anomalies were excluded. Our primary outcome was a composite of obstetrical complications, defined as having one or more of the following: gestational hypertension or preeclampsia, placenta abruption, FGR, or fetal demise. The UtAPI was obtained at the time of enrollment. Logistic regression models with receiver operating curves were used to determine the predictive value of the UtAPI for obstetrical complications. A p value of <.05 was considered significant.Results: A total of 103 patients met inclusion criteria, of those 37 (36%) developed an obstetrical complication (FGR = 22 (21.5%); preeclampsia or gestational hypertension = 9 (9%); placental abruption = 8 (8%); fetal demise = 1 (1%)). Six mothers had more than one complication. The UtAPI was not a statistically significant predictor of a composite of obstetrical complications (AUC = 0.61; p = .07) or for any of the individual complications studied.Conclusions: The UtAPI appears to have limited clinical value for the prediction of obstetrical complications previously associated with abnormal uterine artery Doppler indices in pregnancies with PPROM. Larger and more diverse studies are needed to corroborate our findings.Brief rationale: An accurate prediction for adverse outcomes in patients with PPROM may help identify those that may benefit from increased surveillance protocols.
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Affiliation(s)
- Jose R Duncan
- Department of Obstetrics and Gynecology, University of Tennessee Health Science Center, Memphis, TN, USA.,Department of Obstetrics and Gynecology, University of South Florida, Tampa, FL, USA
| | - Katherine M Dorsett
- Department of Obstetrics and Gynecology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Gustavo Vilchez
- Department of Obstetrics and Gynecology, University of Missouri - Kansas City School of Medicine, Kansas City, MO, USA
| | - Mauro H Schenone
- Department of Obstetrics and Gynecology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Giancarlo Mari
- Department of Obstetrics and Gynecology, University of Tennessee Health Science Center, Memphis, TN, USA
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Beta J, Zhang W, Geris S, Kostiv V, Akolekar R. Procedure-related risk of miscarriage following chorionic villus sampling and amniocentesis. Ultrasound Obstet Gynecol 2019; 54:452-457. [PMID: 30977213 DOI: 10.1002/uog.20293] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 03/17/2019] [Accepted: 03/30/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVES To estimate the procedure-related risks of miscarriage following chorionic villus sampling (CVS) and amniocentesis in a large unselected screened population, and to determine whether these risks are consistent with those reported in systematic reviews and meta-analyses. METHODS This was a retrospective cohort study carried out on data obtained from a large fetal medicine unit in the UK between January 2009 and May 2018. We included all women with singleton pregnancy who booked for pregnancy care at our unit before 20 weeks' gestation, after excluding those with multiple pregnancy, major fetal defect, pregnancy termination and loss to follow-up. We estimated the risk of miscarriage in women who underwent a CVS or amniocentesis as well as in those who did not have an invasive procedure. The procedure-related risk of miscarriage was estimated as risk difference (95% CI) between the two groups. Univariate and multivariate regression analyses were used to derive odds ratios (95% CI) and determine which maternal and pregnancy characteristics provided a significant contribution in the prediction of miscarriage and whether CVS or amniocentesis provided a significant independent contribution. RESULTS During the study period, 45 120 singleton pregnancies were booked for pregnancy care at our hospital, of which 1546 had an invasive procedure. We excluded 1429 (3.2%) pregnancies due to fetal defects, termination of pregnancy or missing outcomes. Of the 43 691 pregnancies included in the study population, 861 underwent CVS and 375 amniocentesis. In pregnancies that underwent CVS, the risk of miscarriage was 1.5% (13/861), compared with 1.2% (476/39 152) in pregnancies that had first-trimester combined screening and did not have an invasive procedure (P = 0.437). In pregnancies that underwent an amniocentesis, the risk of miscarriage was 0.8% (3/375), compared with 1.2% (491/42 463) in those that did not undergo an invasive procedure (P = 0.520). Univariate and multivariate regression analysis demonstrated that there was no significant contribution in the prediction of the risk of miscarriage from CVS (P = 0.399 and P = 0.592, respectively) or amniocentesis (P = 0.543 and P = 0.550, respectively). The risk of procedure-related loss attributed to CVS was 0.29% (95% CI, -0.53 to 1.12%) and that following amniocentesis was -0.36% (95% CI, -1.26 to 0.55%), which was not significantly different from the risk in women who did not have any procedure. CONCLUSIONS The procedure-related risks of miscarriage following CVS and amniocentesis in our study are considerably lower than those currently quoted and are consistent with the estimates of such risks reported by systematic reviews and meta-analyses. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- J Beta
- Fetal Medicine Unit, Medway Maritime Hospital, Gillingham, UK
| | - W Zhang
- Fetal Medicine Unit, Medway Maritime Hospital, Gillingham, UK
| | - S Geris
- Fetal Medicine Unit, Medway Maritime Hospital, Gillingham, UK
| | - V Kostiv
- Fetal Medicine Unit, Medway Maritime Hospital, Gillingham, UK
| | - R Akolekar
- Fetal Medicine Unit, Medway Maritime Hospital, Gillingham, UK
- Institute of Medical Sciences, Canterbury Christ Church University, Chatham, UK
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Robeck TR, Amaral RS, da Silva VMF, Martin AR, Montano GA, Brown JL. Thyroid hormone concentrations associated with age, sex, reproductive status and apparent reproductive failure in the Amazon river dolphin ( Inia geoffrensis). Conserv Physiol 2019; 7:coz041. [PMID: 31384468 PMCID: PMC6669313 DOI: 10.1093/conphys/coz041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 05/06/2019] [Accepted: 06/11/2019] [Indexed: 06/10/2023]
Abstract
This study was conducted to characterize immunoreactive thyroid hormone concentrations in wild Amazon river dolphins, also called boto (Inia geoffrensis) by age group, sex, pregnancy and lactation status, and to determine if thyroid hormone concentration differences could be detected between pregnant females with and without successful parturition outcomes. Radioimmunoassays were used to analyse total T 3 and total T 4 in 182 serum samples collected from 172 botos living in the Mamirauá Sustainable Development Reserve, in the Brazilian Amazon from 2003 through 2015. Age significantly affected tT 3 and tT 4 concentrations in males, with values in immature males and females being significantly lower than those in adult males, whereas no age effects were noted between immature females and adult non-pregnant, non-lactating females. Significant sex differences were noted in tT 3 concentrations between immature males and females and in tT 4 concentrations between adult males and females. These resulted in significant differences in the tT 3:tT 4 ratio between males and females within the immature and adult groups. Lactating and non-pregnant adult females had significantly higher tT 3 concentrations than pregnant females, and this difference was primarily driven by a 12% drop in tT 3 concentrations during the last two-thirds of pregnancy. No differences in thyroid hormone concentrations were detected between females diagnosed as pregnant and later found to have or not have a live calf. These results are the first to define thyroid hormone reference intervals and normal physiological variations in a wild population of river dolphins.
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Affiliation(s)
- T R Robeck
- Species Preservation Laboratory, SeaWorld Parks and Entertainment, 2595 Ingraham Rd, San Diego, CA 92109, USA
| | - R S Amaral
- Federal Institute of Education, Science and Technology of Amazonas—IFAM/CMZL, Av. Cosme Ferreira 8045, Manaus 69086-475, Brazil
| | - V M F da Silva
- Laboratory of Aquatic Mammals, National Institute of Amazonian Research—INPA, Av Andre Araujo 2936, Manaus 69067-375, Brazil
| | - A R Martin
- Centre for Remote Environments, University of Dundee, Nethergate, Dundee DD1 4HN, UK
| | - G A Montano
- Species Preservation Laboratory, SeaWorld Parks and Entertainment, 2595 Ingraham Rd, San Diego, CA 92109, USA
| | - J L Brown
- Center for Species Survival, Smithsonian Conservation Biology Institute, 1500 Remount Road, Front Royal, VA 22630, USA
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Sharvit M, Klein Z, Silber M, Pomeranz M, Agizim R, Schonman R, Fishman A. Intra-amniotic digoxin for feticide between 21 and 30 weeks of gestation: a prospective study. BJOG 2019; 126:885-889. [PMID: 30703286 DOI: 10.1111/1471-0528.15640] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Intra-amniotic injection of digoxin is a well-known method for feticide before inducing a termination of pregnancy (TOP) at 17-24 weeks of gestation. Information on its effectiveness when administered after 24 weeks of gestation is limited. This study evaluated the efficacy of intra-amniotic digoxin injection for inducing fetal demise within 18-24 hours, at 21-30 weeks of gestation, and its safety. DESIGN Prospective cohort study. SETTING Tertiary university medical centre. POPULATION Women at 21-30 weeks of gestation with a singleton pregnancy, admitted for TOP. METHODS Intra-amniotic injection of 2 mg of digoxin was performed 1 day before medical TOP. Fetal heart activity was evaluated by ultrasound for 18-24 hours after the injection. Serum digoxin level and maternal electrocardiogram (ECG) were evaluated 6, 10, and 20 hours after injection. MAIN OUTCOME MEASURE Frequency of successful fetal demise. RESULTS Fifty-nine women participated in the study. The mean gestational age was 24+2 weeks (range 21+0 -30+0 ), with 29 (49.2%) beyond 24+0 weeks of gestation. Fetal cardiac activity arrest was achieved in 55/59 cases (93.2%). Normal maternal ECG recordings were noted in all cases. Mean serum digoxin levels 6 and 10 hours after injection were in the therapeutic range (1.3 ± 0.7 ng/l and 1.24 ± 0.49 ng/l, respectively) and below the toxic level (2 ng/l). Extramural delivery following digoxin did not occur. There were no cases of chorioamnionitis. CONCLUSION Intra-amniotic digoxin for feticide at 21-30 weeks of gestation in a singleton pregnancy appears effective and safe before TOP at advanced gestational ages. TWEETABLE ABSTRACT This study shows that feticide by intra-amniotic digoxin injection at 21-30 weeks of gestation appears effective and safe.
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Affiliation(s)
- M Sharvit
- Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel
| | - Z Klein
- Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel.,Sackler School of Medicine, Tel Aviv University, Israel
| | - M Silber
- Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel.,Sackler School of Medicine, Tel Aviv University, Israel
| | - M Pomeranz
- Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel.,Sackler School of Medicine, Tel Aviv University, Israel
| | - R Agizim
- Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel.,Sackler School of Medicine, Tel Aviv University, Israel
| | - R Schonman
- Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel.,Sackler School of Medicine, Tel Aviv University, Israel
| | - A Fishman
- Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel.,Sackler School of Medicine, Tel Aviv University, Israel
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Tai W, Voronin D, Chen J, Bao W, Kessler DA, Shaz B, Jiang S, Yazdanbakhsh K, Du L. Transfusion-Transmitted Zika Virus Infection in Pregnant Mice Leads to Broad Tissue Tropism With Severe Placental Damage and Fetal Demise. Front Microbiol 2019; 10:29. [PMID: 30728813 PMCID: PMC6351479 DOI: 10.3389/fmicb.2019.00029] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 01/09/2019] [Indexed: 01/10/2023] Open
Abstract
Zika virus (ZIKV) infection during pregnancy can cause significant problems, particularly congenital Zika syndrome. Nevertheless, the potential deleterious consequences and associated mechanisms of transfusion-transmitted ZIKV infection on pregnant individuals and their fetuses and babies have not been investigated. Here we examined transmissibility of ZIKV through blood transfusion in ZIKV-susceptible pregnant A129 mice. Our data showed that transfused-transmitted ZIKV at the early infection stage led to significant viremia and broad tissue tropism in the pregnant recipient mice, which were not seen in those transfused with ZIKV-positive (ZIKV+) plasma at later infection stages. Importantly, pregnant mice transfused with early-stage, but not later stages, ZIKV+ plasma also exhibited severe placental infection with vascular damage and apoptosis, fetal infection and fetal damage, accompanied by fetal and pup death. Overall, this study suggests that transfusion-related transmission of ZIKV during initial stage of infection, which harbors high plasma viral titers, can cause serious adverse complications in the pregnant recipients and their fetuses and babies.
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Affiliation(s)
- Wanbo Tai
- Lindsley F. Kimball Research Institute, New York Blood Center, New York, NY, United States
| | - Denis Voronin
- Lindsley F. Kimball Research Institute, New York Blood Center, New York, NY, United States
| | - Jiawei Chen
- Lindsley F. Kimball Research Institute, New York Blood Center, New York, NY, United States
| | - Weili Bao
- Lindsley F. Kimball Research Institute, New York Blood Center, New York, NY, United States
| | - Debra A Kessler
- Lindsley F. Kimball Research Institute, New York Blood Center, New York, NY, United States
| | - Beth Shaz
- Lindsley F. Kimball Research Institute, New York Blood Center, New York, NY, United States
| | - Shibo Jiang
- Lindsley F. Kimball Research Institute, New York Blood Center, New York, NY, United States.,Key Laboratory of Medical Molecular Virology of MOE/MOH, Fudan University, Shanghai, China
| | - Karina Yazdanbakhsh
- Lindsley F. Kimball Research Institute, New York Blood Center, New York, NY, United States
| | - Lanying Du
- Lindsley F. Kimball Research Institute, New York Blood Center, New York, NY, United States
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Korlesky C, McPherson E. Early demise of twins in a cohort of stillbirths and second trimester miscarriages. Am J Med Genet A 2019; 179:350-355. [PMID: 30663217 DOI: 10.1002/ajmg.a.61014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 11/08/2018] [Accepted: 11/16/2018] [Indexed: 11/11/2022]
Abstract
Twins, particularly monochorionic (MC) pairs, are at increased risk for fetal death. Whereas previous work has sought to understand the mechanisms for this increased mortality, most studies analyze viable twin pregnancies or liveborn twin cohorts. In the Wisconsin Stillbirth Service Program cohort of 3,137 stillbirths and second trimester miscarriages, we identified 175 twin pregnancies for a twinning rate of 56/1,000, which is approximately double the general population. The excess of twins among miscarriages and stillbirths was attributable to MC pairs as the incidence of dizygotic (DZ) twinning was not increased compared to livebirth data. The leading causes of fetal demise among twins were twin-twin transfusion, acardia, and twin-twin disruption. Maternal causes of death, primarily premature rupture of membranes, were moderately increased in both MC and DZ twins relative to singletons. Although deceased twins were smaller than expected for viable twins at comparable gestational ages, placenta weights of deceased MC pairs were large compared to combined fetal weight, which indicates placental inefficiency likely due to vascular shunting. Co-twin survival was much lower for MC than for DZ pairs. Therefore, earlier diagnosis and treatment of MC twinning complications may decrease prenatal mortality.
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Affiliation(s)
- Colin Korlesky
- Center for Human Genetics, Marshfield Clinic Research Institute, Marshfield, Wisconsin
| | - Elizabeth McPherson
- Center for Human Genetics, Marshfield Clinic Research Institute, Marshfield, Wisconsin
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Sutherland M, Craver R. Multifocal Rounded Intraplacental Hematomas, Placental Abruption and Intrauterine Fetal Demise. Fetal Pediatr Pathol 2018; 37:465-469. [PMID: 30592229 DOI: 10.1080/15513815.2018.1520373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Rounded intraplacental hematomas (RIH) have a distinct rounded hemorrhagic appearance located within the placental parenchyma. Hemorrhagic villous infarctions (infarcts that when sectioned have hemorrhagic centers) are probably older RIH. RIH have been associated with acute abruptions. CASE REPORT We describe multiple RIHs and hemorrhagic villous infarctions in various stages of development that arose between 20 and 27 weeks gestation, demonstrated by ultrasound, that developed an acute abruption and fetal death. CONCLUSIONS The findings of RIHs, hemorrhagic infarcts, and lesions in between support the evolution of hemorrhagic villous infarctions from RIHs. These lesions can arise in the second trimester, and can be detected by ultrasound. These multiple lesions in various stages of evolution suggest an ongoing rather than a discrete insult.
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Affiliation(s)
- Monique Sutherland
- a Department of Obstetrics and Gynecology , Louisiana State University Health Sciences Center , New Orleans , Louisiana , USA
| | - Randall Craver
- b Laboratory , Children's Hospital of New Orleans , New Orleans , Louisiana , USA.,c Department of Pathology , LSUHSC , New Orleans , Louisiana , USA
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Abstract
Background Although rare, familial hypertriglyceridemia can cause acute and life-threatening complications in pregnancy. Cases The first patient's pregnancy was complicated by multiple admissions for pancreatitis due to hypertriglyceridemia and noncompliance with gemfibrozil. In her second pregnancy, she was compliant with gemfibrozil and only experienced pancreatitis episodes toward the end of pregnancy. The second patient had diabetes mellitus and familial hypertriglyceridemia. She required multiple hospitalizations for diabetic ketoacidosis secondary to insulin noncompliance. In both pregnancies, she was compliant with gemfibrozil and had no complications related to hypertriglyceridemia. Conclusion Treatment with gemfibrozil in pregnancies complicated by hypertriglyceridemia may prevent complications without adverse maternal or fetal effects and could be considered in treating pregnant patients with severe hypertriglyceridemia. These cases also demonstrate the importance of medication compliance in the prevention of poor outcomes.
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Affiliation(s)
- Suzanne Cao
- Department of Women's Health, Arrowhead Regional Medical Center, Colton, California
| | - NhuChi Dao
- Department of Women's Health, Arrowhead Regional Medical Center, Colton, California
| | - Kristina Roloff
- Department of Women's Health, Arrowhead Regional Medical Center, Colton, California
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Abstract
The differential diagnosis of third trimester bleeding can range from placenta abruptia to placenta previa to uterine rupture and the placenta accreta spectrum (PAS). However, patients with risk factors such as multiple cesarean sections (c-sections), advanced maternal age (AMA), grand multiparity, and single-layer uterine closure are at greater risk of developing these complications earlier than we would traditionally expect. This case recounts a 38-year-old gravida 6 preterm 3 term 1 abortus 1 live 4 (G6P3114) at 23 weeks and five days gestational age (GA) with a past medical history of preterm pregnancy, pre-eclampsia, chronic abruptia, three previous c-sections, and low-lying placenta who presented to the emergency department (ED) with vaginal bleeding. Initial workup revealed placenta accreta and possible percreta. The patient was placed on intramuscular (IM) corticosteroids in anticipation of preterm delivery. As soon as the patient was stable, she was discharged home. She presented to a different hospital the next day with the same complaints. Imaging was consistent with accreta and her presentation with abruption. During the hospital stay, the patient went into threatened preterm labor (PTL). At first, we suspected preterm premature rupture of membranes (PPROM) due to apparent pooling of amniotic fluid in the vaginal canal. Upon further work up, the diagnosis was consistent with chronic abruption oligohydramnios sequence (CAOS). Before this could be investigated, her hospital course was complicated by acute abruption and Category III/nonreassuring fetal heart rate (FHR) tracing. The patient underwent an emergency c-section at 26 weeks GA as well as a planned supracervical hysterectomy for desired permanent sterilization. During the operation, the patient suffered a postpartum hemorrhage (PPH) of 4500 mL. She was later discharged home on postoperative day (POD) eight.
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Affiliation(s)
- Joshua A Ronen
- Internal Medicine, Texas Tech University Health Sciences Center of the Permian Basin, Odessa, USA
| | - Krystal Castaneda
- MS3/Ross University School of Medicine, California Hospital Medical Center, Los Angeles, USA
| | - Sara Y Sadre
- MS4/Ross University School of Medicine, California Hospital Medical Center, Los Angeles, USA
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di Pasquo E, Kuleva M, O'Gorman N, Ville Y, Salomon LJ. Fetal intra-abdominal umbilical vein varix: retrospective cohort study and systematic review and meta-analysis. Ultrasound Obstet Gynecol 2018; 51:580-585. [PMID: 28876490 DOI: 10.1002/uog.18895] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2017] [Revised: 08/18/2017] [Accepted: 08/24/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To investigate the ultrasound characteristics and outcome of pregnancies with fetal intra-abdominal umbilical vein varix (FIUVV). METHODS Cases of FIUVV managed at our tertiary university hospital over an 8-year period were reviewed. Information retrieved included gestational age and diameter of the umbilical varix at diagnosis, increase in varix diameter, associated ultrasound or chromosomal anomalies and pregnancy outcome. Furthermore, a systematic review and meta-analysis of series of FIUVV in the literature was performed to assess the incidence of chromosomal anomalies, small-for-gestational age infants and intrauterine fetal demise (IUFD), and to pool odds ratio (OR) estimates on the relationship between the incidence of these outcomes and the presence of additional associated ultrasound anomalies. RESULTS Thirteen cases of FIUVV were included in the cohort study. Additional ultrasound anomalies were found in two (15.4%) of 13 cases. One case of IUFD was observed and no case of chromosomal anomaly or thrombosis of varix was recorded. A total of five studies comprising 254 cases met the inclusion criteria of the systematic review. FIUVV was associated with additional ultrasound anomalies (non-isolated FIUVV) in 19% (95% CI, 10.9-29.1%) of cases. No case of chromosomal abnormality or IUFD was reported in fetuses with isolated FIUVV. In contrast, in the group of non-isolated FIUVV, the incidence of chromosomal anomalies was 19.6% and that of IUFD was 7.3%, with ORs of 14.8 (95% CI, 2.9-73.0) and 8.2 (95% CI, 1.05-63.1), respectively, when compared with the group of isolated FIUVV. CONCLUSION When isolated, the outcome of cases affected by FIUVV is usually favorable. In about 20% of cases, additional ultrasound anomalies are found, which are associated with an increased risk for chromosomal abnormalities and IUFD. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- E di Pasquo
- Maternité Hôpital Necker-Enfants Malades, Assistance Publique, Hôpitaux de Paris, Université Paris Descartes, Paris, France
| | - M Kuleva
- Maternité Hôpital Necker-Enfants Malades, Assistance Publique, Hôpitaux de Paris, Université Paris Descartes, Paris, France
| | - N O'Gorman
- Maternité Hôpital Necker-Enfants Malades, Assistance Publique, Hôpitaux de Paris, Université Paris Descartes, Paris, France
| | - Y Ville
- Maternité Hôpital Necker-Enfants Malades, Assistance Publique, Hôpitaux de Paris, Université Paris Descartes, Paris, France
- Société Française pour l'Amélioration des Pratiques Echographiques, Paris, France
| | - L J Salomon
- Maternité Hôpital Necker-Enfants Malades, Assistance Publique, Hôpitaux de Paris, Université Paris Descartes, Paris, France
- Société Française pour l'Amélioration des Pratiques Echographiques, Paris, France
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Bollweg BC, Silva-Flannery L, Spivey P, Hale GL. Optimization of commercially available Zika virus antibodies for use in a laboratory-developed immunohistochemical assay. J Pathol Clin Res 2017; 4:19-25. [PMID: 29416874 PMCID: PMC5783976 DOI: 10.1002/cjp2.84] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 09/26/2017] [Accepted: 10/02/2017] [Indexed: 12/22/2022]
Abstract
Zika virus (ZIKV) infection during pregnancy can cause adverse fetal outcomes and severe irreversible congenital birth defects including microcephaly. Immunohistochemistry (IHC) is a valuable diagnostic tool for detecting ZIKV antigens in tissues from cases of fetal loss in women infected with ZIKV, and for providing insights into disease pathogenesis. As a result, there is increasing demand for commercially available ZIKV antibodies for use in IHC assays. ZIKV antibodies were selected and obtained from commercial sources to include both mouse and rabbit hosts, and a variety of antigenic targets. Pretreatment conditions and antibody concentrations resulting in optimal immunohistochemical staining were determined using ZIKV cell control and polymerase chain reaction (PCR)‐confirmed ZIKV case control material (fetal brain tissue). Cross‐reactivity of the antibodies against other flaviviruses (dengue virus serogroups 1–4, yellow fever virus, Japanese encephalitis virus, West Nile virus) and chikungunya virus was also evaluated. Immunostaining using the commercially available antibodies was compared to a previously validated ZIKV IHC assay used for primary diagnosis. Four antibodies demonstrated optimal staining similar to the previously validated ZIKV IHC assay. Two of the four antibodies cross‐reacted with dengue virus, while the other two antibodies showed no cross‐reactivity with dengue, other flaviviruses, or chikungunya virus. Differences in the cross‐reactivity profiles could not be entirely explained by the antigenic target. Commercially available ZIKV antibodies can be optimized for use in IHC testing to aid in ZIKV diagnostic testing and an evaluation of tissue tropism.
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Affiliation(s)
- Brigid C Bollweg
- Infectious Diseases Pathology BranchCenters for Disease Control and PreventionAtlantaGAUSA
| | - Luciana Silva-Flannery
- Infectious Diseases Pathology BranchCenters for Disease Control and PreventionAtlantaGAUSA
| | - Pamela Spivey
- Infectious Diseases Pathology BranchCenters for Disease Control and PreventionAtlantaGAUSA
| | - Gillian L Hale
- Infectious Diseases Pathology BranchCenters for Disease Control and PreventionAtlantaGAUSA
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Hamza A, Meyberg-Solomayer G, Juhasz-Böss I, Joukhadar R, Takacs Z, Solomayer EF, Baum S, Radosa J, Mavrova L, Herr D. Diagnostic Methods of Ectopic Pregnancy and Early Pregnancy Loss: a Review of the Literature. Geburtshilfe Frauenheilkd 2016; 76:377-382. [PMID: 27134292 DOI: 10.1055/s-0041-110204] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
This review article presents recent evidence on early pregnancy loss and ectopic pregnancy. In the light of recent evidence, the β-hCG discriminatory zone may be extended in clinically stable cases without evidence of bleeding. A possible cut-off is 4300 mIU/ml, which corresponds to when a sonographer should detect an intrauterine pregnancy. Embryonic demise can be confirmed when a transvaginal ultrasound finding shows no heartbeat in an embryo of more than 7 mm CRL, no embryo in a gestational sac having a mean sac diameter of more than 25 mm, or no appearance of an embryo within 7-10 days after the primary examination. These are considered definitive signs of embryonic demise. Suggestive signs of embryonic demise require closer monitoring of the pregnancy.
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Affiliation(s)
- A Hamza
- Department of Obstetrics and Gynaecology, Homburg University Medical Centre, Homburg
| | - G Meyberg-Solomayer
- Department of Obstetrics and Gynaecology, Homburg University Medical Centre, Homburg
| | - I Juhasz-Böss
- Department of Obstetrics and Gynaecology, Homburg University Medical Centre, Homburg
| | - R Joukhadar
- Department of Obstetrics and Gynaecology, Homburg University Medical Centre, Homburg
| | - Z Takacs
- Department of Obstetrics and Gynaecology, Homburg University Medical Centre, Homburg
| | - E-F Solomayer
- Department of Obstetrics and Gynaecology, Homburg University Medical Centre, Homburg
| | - S Baum
- Department of Obstetrics and Gynaecology, Homburg University Medical Centre, Homburg
| | - J Radosa
- Department of Obstetrics and Gynaecology, Homburg University Medical Centre, Homburg
| | - L Mavrova
- Department of Obstetrics and Gynaecology, Homburg University Medical Centre, Homburg
| | - D Herr
- Department of Obstetrics and Gynaecology, Würzburg University Medical Centre, Würzburg
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Abstract
Apple peel deformity is a rare form of upper intestinal atresia of unknown etiology. Umbilical cord ulcers can occur secondary to reflux of gastric juice and bile as a result of the atresia and can cause lethal intrauterine hemorrhage. The authors report 3 instances of congenital apple peel jejunal atresia with helical umbilical cord ulcers afflicting all female offspring in consecutive pregnancies in a single nonconsanguineous family. There was no hemorrhage from the cord ulcers, but all 3 pregnancies resulted in perinatal death. Although familial occurrence is known, our case series is probably the 1st from the Indian subcontinent and warrants further research into the genetic mechanisms and possible ethnic differences of congenital upper intestinal atresia. The causation of sudden fetal demise in the absence of antecedent cord hemorrhage remains elusive.
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Affiliation(s)
- Sunil Jaiman
- 1 Department of Anatomic and Perinatal Pathology & Cytology, Fernandez Hospital Unit 3, Plot 769, Road No. 44, Jubilee Hills, Hyderabad-500033, India
| | - Sirisha Rao Gundabattula
- 2 Department of Gynaecology, Fernandez Hospital Unit 3, Plot 769, Road No. 44, Jubilee Hills, Hyderabad 500033, India
| | - Chinmayee Ratha
- 3 Department of Fetal Medicine, Rainbow Hospital, 22, Road No. 4, Karvy Lanes, Banjara Hills, Hyderabad-500034, India
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43
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Abstract
It is well established that the death of one fetus in a monochorionic twin pregnancy places the surviving twin at significant risk for neuro-developmental delay or death. Although the early 1st trimester "vanishing twin" has not traditionally been considered a major risk, the precise gestational threshold beyond which a surviving twin is at risk remains uncertain. Most experts recommend serial ultrasounds and fetal MRI in the survivor, to look for evidence of ischaemic brain injury. We present a case of early monochorionic twin demise at 14-16 weeks, with evolving ventriculomegaly and ischaemic changes on fetal MRI in the co-twin, leading to termination of pregnancy at 28 weeks.
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Affiliation(s)
- Colin A Walsh
- Department of Fetal MedicineRoyal North Shore HospitalSydneyNew South WalesAustralia; Northern Clinical School University of SydneySydneyNew South WalesAustralia
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44
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Rosenfeld JA, Tucker ME, Escobar LF, Neill NJ, Torchia BS, McDaniel LD, Schultz RA, Chong K, Chitayat D. Diagnostic utility of microarray testing in pregnancy loss. Ultrasound Obstet Gynecol 2015; 46:478-486. [PMID: 25846569 DOI: 10.1002/uog.14866] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Revised: 03/25/2015] [Accepted: 03/29/2015] [Indexed: 06/04/2023]
Abstract
OBJECTIVES To determine the frequency of clinically significant chromosomal abnormalities identified by chromosomal microarray in pregnancy losses at any gestational age and to compare microarray performance with that of traditional cytogenetic analysis when testing pregnancy losses. METHODS Among 535 fetal demise specimens of any gestational age, clinical microarray-based comparative genomic hybridization (aCGH) was performed successfully on 515, and a subset of 107 specimens underwent additional single nucleotide polymorphism (SNP) analysis. RESULTS Overall, clinically significant abnormalities were identified in 12.8% (64/499) of specimens referred with normal or unknown karyotypes. Detection rates were significantly higher with earlier gestational age. In the subset with normal karyotype, clinically significant abnormalities were identified in 6.9% (20/288). This detection rate did not vary significantly with gestational age, suggesting that, unlike aneuploidy, the contribution of submicroscopic chromosomal abnormalities to fetal demise does not vary with gestational age. In the 107 specimens that underwent aCGH and SNP analysis, seven cases (6.5%) had abnormalities of potential clinical significance detected by the SNP component, including female triploidy. aCGH failed to yield fetal results in 8.3%, which is an improvement over traditional cytogenetic analysis of fetal demise specimens. CONCLUSIONS Both the provision of results in cases in which karyotype fails and the detection of abnormalities in the presence of a normal karyotype demonstrate the increased diagnostic utility of microarray in pregnancy loss. Thus, chromosomal microarray testing is a preferable, robust method of analyzing cases of pregnancy loss to better delineate possible genetic etiologies, regardless of gestational age.
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Affiliation(s)
- J A Rosenfeld
- Signature Genomic Laboratories, PerkinElmer, Inc., Spokane, WA, USA
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
| | - M E Tucker
- St. Vincent Hospital, Indianapolis, IN, USA
| | | | - N J Neill
- Signature Genomic Laboratories, PerkinElmer, Inc., Spokane, WA, USA
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
| | - B S Torchia
- Signature Genomic Laboratories, PerkinElmer, Inc., Spokane, WA, USA
| | - L D McDaniel
- Signature Genomic Laboratories, PerkinElmer, Inc., Spokane, WA, USA
| | - R A Schultz
- Signature Genomic Laboratories, PerkinElmer, Inc., Spokane, WA, USA
| | - K Chong
- The Prenatal Diagnosis and Medical Genetics Program, Mount Sinai Hospital, University of Toronto, Ontario, Canada
| | - D Chitayat
- The Prenatal Diagnosis and Medical Genetics Program, Mount Sinai Hospital, University of Toronto, Ontario, Canada
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45
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Abstract
OBJECTIVE There are no national reports on the mode of delivery in pregnancies that end in stillbirth. We aimed at analyzing the cesarean delivery rates in pregnancies resulting in stillbirth over a 10-year period in the United States. MATERIALS AND METHODS This was a retrospective analysis evaluating data from the 1995 to 2004 US linked live birth-infant death files reported by the National Center for Health Statistics to examine the cesarean delivery rates in singleton pregnancies with and without stillbirth. RESULTS There were 39 797 616 singleton births registered in the database after the 20th week of gestation. During the study period, there were 243 979 stillbirths (0.61 per 100). Significant differences in stillbirths were noted in the African American population, nonmarried patients, in mothers who smoked, and at the extremes of the patients reproductive age (P < .01). The overall cesarean delivery rate in liveborn was 23.54% (9 309 961 cases) and 10.5% in stillbirth (25 558 cases; P < .01). The rate of cesarean delivery increased in liveborn (from 20.8% in 1995 to 28.9% in 2004; 28% overall increase) and in stillbirth (9.5% in 1995 to 11.23% in 2004; 15% overall increase). The rates of primary and repeat cesarean operations increased with gestational age in the stillbirth group. This pattern was not observed in the liveborn group. CONCLUSION This analysis indicates that the cesarean delivery rates increased both in liveborn and in stillbirth from 1995 to 2004. This epidemiological observation deserves new clinical investigations to understand the clinical reasons, driving this obstetrical practice and the financial and societal impact that it portends.
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Affiliation(s)
- Valeria Di Stefano
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Joaquín Santolaya-Forgas
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA The Perinatal Institute, Jersey Shore University Medical Center, Neptune, NJ 07753, USA
| | - Revital Faro
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Christina Duzyj
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Yinka Oyelese
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA The Perinatal Institute, Jersey Shore University Medical Center, Neptune, NJ 07753, USA
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46
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Jacques SM, Kupsky WJ, Qureshi F. Acute thymic involution in unexplained third trimester stillbirth: frequency, grade, and correlation with neuropathologic injury. Pediatr Dev Pathol 2015; 18:210-7. [PMID: 25668742 DOI: 10.2350/14-11-1577-oa.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Many 3rd-trimester stillbirths are unexplained, including the time course of the illness. Histologic acute thymic involution (ATI), when graded, correlates with duration of acute illness (grade 0, <12 hours; grade 4, >72 hours). Histologic brain injury is also common in stillbirth. We investigated ATI in unexplained stillbirth and correlated it with neuropathologic injury by identifying 58 autopsies of unexplained, 3rd-trimester stillborns (preterm, n = 24; term, n = 34) that included brain examination and graded ATI from 0 (resting state) to 4 (pronounced lymphodepletion). Gray matter injury (GMI) and white matter injury (WMI) were classified as older, recent, or absent, and ATI was correlated with GMI, WMI, thymic weight, and clinical data. Nine cases (16%) had ATI grade 0-1; 19 (33%), grade 2; 24 (41%), grade 3; and 6 (10%), grade 4. Older GMI and WMI were present in 39 (67%) and 10 (17%) stillborns, respectively. Higher ATI grade correlated significantly with older GMI (P < 0.001) and WMI (P = 0.014). The ATI grade was higher in the small-for-gestational stillborns compared with the appropriate- or large-for-gestational stillborns (P = 0.017) but did not correlate significantly with gestational age or other clinical or demographic factors evaluated. The ATI grades 2-4 were found in 84% of the stillborns, consistent with onset of acute illness between 24 and >72 hours before demise. Higher ATI grade correlated significantly with older brain injury, suggesting similar time of onset and shared underlying pathophysiologic events, the specific nature of which remains unclear.
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Affiliation(s)
- Suzanne M. Jacques
- Department of Pathology, Detroit Medical Center and Wayne State University School of Medicine, Harper University Hospital/Hutzel Women's Hospital, 3990 John R, Detroit, Ml 48201, USA
| | - William J. Kupsky
- Department of Pathology, Detroit Medical Center and Wayne State University School of Medicine, Harper University Hospital/Hutzel Women's Hospital, 3990 John R, Detroit, Ml 48201, USA
| | - Faisal Qureshi
- Department of Pathology, Detroit Medical Center and Wayne State University School of Medicine, Harper University Hospital/Hutzel Women's Hospital, 3990 John R, Detroit, Ml 48201, USA
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47
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Blumenfeld Z, Khatib N, Zimmer EZ, Bronshtein M. Fetal demise in the early second trimester: sonographic findings. J Clin Ultrasound 2015; 43:109-112. [PMID: 24990444 DOI: 10.1002/jcu.22204] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Revised: 06/09/2014] [Accepted: 06/09/2014] [Indexed: 06/03/2023]
Abstract
PURPOSE To report the etiology and the sonographic findings of fetal demise at 14-17 weeks' gestation. METHODS A prospective transvaginal sonographic search of fetal anomalies was performed in 61 early second-trimester cases of fetal demise. The findings were compared with the results of sonographic examinations of 22,500 viable fetuses between weeks 14 and 17. RESULTS Of 61 cases of early fetal demise in 60 women (1:370), more than half of the fetuses (35/61, 57%) were associated with fetal edema, ranging from nuchal edema and cystic hygroma to fetal hydrops. In 9/61 (14.7%) fetuses, major anatomic anomalies were detected. There was no significant difference between the study group (nonviable fetuses) and the control group (viable fetuses) regarding maternal age and the prevalence of maternal fever, maternal thrombophilic mutations, vaginal bleeding, fertility treatments, maternal diseases, or use of medications. CONCLUSIONS The incidence of early midtrimester fetal demise is 1:370 pregnancies. The sonographic findings in fetal demise in the early second trimester suggest that 57% of them are associated with fetal edema and 14.7% are associated with major fetal malformations. We did not identify any significant maternal risk factor for fetal demise in the study group.
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Affiliation(s)
- Zeev Blumenfeld
- Department of Ob/Gyn, Rambam Health Care Campus, The Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, 31096, Israel
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48
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Duffey H. Water immersion in neonatal bereavement photography. Nurs Womens Health 2014; 18:429-33. [PMID: 25316544 DOI: 10.1111/1751-486x.12152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Water immersion in neonatal bereavement photography is a new technique intended to enhance the quality of the photographs provided to families following their loss. Water immersion appears to be most helpful following a second trimester fetal demise. This technique can be used by nurses, professional photographers and others in addition to more traditional neonatal bereavement photography. It does not require special skills or equipment and can be implemented in virtually any perinatal setting. The enhanced quality of photographs produced with this method can potentially provide a source of comfort to grieving families.
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49
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Abstract
AIMS Detection and careful stratification of fetal heart rate (FHR) is extremely important in all pregnancies. The most lethal cardiac rhythm disturbances occur during apparently normal pregnancies where FHR and rhythm are regular and within normal or low-normal ranges. These hidden depolarization and repolarization abnormalities, associated with genetic ion channelopathies cannot be detected by echocardiography, and may be responsible for up to 10% of unexplained fetal demise, prompting a need for newer and better fetal diagnostic techniques. Other manifest fetal arrhythmias such as premature beats, tachycardia, and bradycardia are commonly recognized. METHODS Heart rhythm diagnosis in obstetrical practice is usually made by M-mode and pulsed Doppler fetal echocardiography, but not all fetal cardiac time intervals are captured by echocardiographic methods. RESULTS AND CONCLUSIONS This article reviews different types of fetal arrhythmias, their presentation and treatment strategies, and gives an overview of the present and future diagnostic techniques.
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Affiliation(s)
| | - Janette F. Strasburger
- Division of Cardiology, Department of Pediatrics, Children’s Hospital of Wisconsin-Milwaukee and Fox Valley, Milwaukee, Wisconsin
| | - Bettina F. Cuneo
- Department of Pediatrics, Children’s Hospital Colorado, The Heart Institute, The University of Colorado School of Medicine, Denver, Colorado
| | - Ronald T. Wakai
- Department of Medical Physics, University of Wisconsin, Madison, Wisconsin
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50
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Cain MA, Guidi CB, Steffensen T, Whiteman VE, Gilbert-Barness E, Johnson DR. Postmortem ultrasonography of the macerated fetus complements autopsy following in utero fetal demise. Pediatr Dev Pathol 2014; 17:217-20. [PMID: 24617606 DOI: 10.2350/14-02-1439-cr.1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Postmortem evaluation following an in utero fetal demise is essential for determining cause of death and counseling regarding future pregnancies. Severe maceration and fetal size along with patient desires may limit the physician's ability to perform a complete autopsy. In the cases presented, we demonstrate the utility of postmortem ultrasonography as an adjunct to traditional autopsy following fetal demise.
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Affiliation(s)
- Mary Ashley Cain
- 1 Department of Obstetrics and Gynecology Division of Maternal Fetal Medicine, University of South Florida, Tampa, FL, USA
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