Brain Damage to the Survivor within 30 min of Co-Twin Demise in Monochorionic Twins

Single fetal death in a twin pregnancy in the late second or early third trimester is associated with significant morbidity and mortality rate in the surviving co-twin, especially in monochorionic twin pregnancies. The common causes are twin-to-twin transfusion syndrome, chromosomal abnormalities, and congenital anomalies of the fetus or anomalies of the umbilical cord-placenta. Here we report a case of monochorionic twin pregnancy in which one fetus had a single umbilical artery (SUA) while the co-twin had two umbilical arteries. The twin with SUA died in utero at the 30th week of gestation and the other fetus was delivered by cesarean section immediately due to fetal distress diagnosed by cardiotocography. Disseminated intravascular coagulation and multicystic encephalomalacia have been observed in the surviving neonate. This case and review of the literature suggest that neurologic complication rates are also increased in monochorionic twin pregnancies with single fetal demise despite the immediate delivery as in our case.

Management of other complications specific to monochorionic twin pregnancies

Monochorionic (MC) twins have a 3-10-fold higher perinatal mortality and morbidity than dichorionic twins. This is largely attributable to their common vascular architecture and the high rate of discordant fetal growth, growth restriction and congenital abnormalities. In the event of a single intrauterine death (IUD), intertwin agonal transfusion results in up to a 38% risk of death and a 46% risk of neurological injury to the co-twin. This chapter addresses the management of complications unique to MC twins. The primary aim of management is to prevent single IUD or, if inevitable, prevent agonal transfusion occurring by vascular occlusive selective feticide. Older fetoscopic techniques have been replaced by the simpler ultrasound-guided techniques of interstitial laser and bipolar cord occlusion. Their application in twin reversed-arterial perfusion sequence has been associated with a 50% reduction of perinatal mortality in the pump twin. Moreover, prophylactic interstitial laser therapy in early pregnancy might obviate the technical and clinical difficulties in the presence of fetal decompensation in later pregnancy. Recent strategies to reduce the high perinatal mortality due to cord entanglement in antenatally diagnosed monoamniotic twins including medical amnioreduction and elective caesarean delivery at 32 weeks, are also discussed.

Management of single fetal demise in a multiple gestation

Intrauterine fetal demise of 1 twin in a multiple gestation is a complex clinical situation. Chorionicity, gestational age at diagnosis, problems specific to the pregnancy, and the emotional needs of the patient can impact management. Strategies to optimize outcomes may include a multidisciplinary team approach and fetal surveillance. The following article reviews (1) adverse fetal and neonatal outcomes associated with intrauterine fetal demise of 1 twin, (2) the potential maternal impact, and (3) the strategies to possibly prevent poor outcomes. It is important to remember that even the most vigilant care may not avoid adverse sequelae in a portion of at-risk pregnancies.

[Acute renal failure during HELLP syndrome--case report]

Case report was presented of a 22 year old pregnant patient with diagnosed intrauterine fetal death, who developed HELLP syndrome and acute renal failure. Immediate hemodialysis treatment was initiated that permitted management of pulmonary edema; subsequent plasmapheresis eliminated not only elevated bilirubin and toxins liberated to circulation from the dead intrauterine fetus but also allowed for patient recovery. The HELLP Syndrome requires careful obstetric supervision and if possible treatment in the Intensive Care Unit.

Natural history of twin disruption sequence

Intrauterine death of one fetus in a monochorionic twin pregnancy is associated with high morbidity and mortality in the surviving co-twin. Thromoboplastic material from the dead twin may pass to the circulation of the living twin via placental anastomoses and cause tissue necrosis by direct embolization or by activating intravascular coagulation. Alternatively, acute blood loss into the dying twin through placental anastomoses may result in hypotension and hypoxic-ischemic damage to cerebral and visceral tissue in the surviving twin. The resulting clinical picture is referred to as twin disruption sequence. Affected twins have rarely been followed beyond the neonatal period and the long-term development of such children is unknown. Here, we present a natural history and neurological assessment of 18 patients with twin disruption sequence, whom we have followed over several months to years.

[Case report of 18 weeks delayed delivery of the second twin after the miscarriage of the first fetus at the 17th week of pregnancy]

Delayed delivery of the second twin after the miscarriage of the first foetus is very rare. Delayed second-twin delivery gives the opportunity for corticoid and antibiotics administration--procedures that decrease the infant morbidity and mortality. We report a case of the second twin's retention after miscarriage of the first at 17th week of pregnancy. The delay time was of 126 days (18 weeks). Pregnancy like this is at increased risk for all maternal complications, in particular intrauterine infection. Parents consent have to be obtained after informing them about advantages and risk of such procedure. The patient was treated with tocolysis, antibiotics, corticosteroids but not previous cervix cerclage has been performed. On regards of our experience and the data from literature we conclude that when observing fetal status and maternal condition, it is possible to delay the second twin's delivery long time after the miscarriage or birth of the first one thus giving the chance to the second twin to grow more mature. The main problem is imminent infection which defines the prognosis. Cerclage does not seem to be essential for better outcome.

Neuromorbidity in preterm twins in relation to chorionicity and discordant birth weight

OBJECTIVE

The purpose of this study was to determine the incidence of neurologic morbidity in preterm monochorionic (MC) and dichorionic (DC) twins.

STUDY DESIGN

We collected perinatal, neonatal, and infant follow-up data of 76 MC and 78 DC twins born between 24 and 34 weeks of gestation (295 infants). Risks of neuromorbidity in the surviving infants were evaluated in relation to chorionicity, discordant birth weight (>20%), twin-twin transfusion syndrome (TTTS), and cotwin death.

RESULTS

The overall incidence of cerebral palsy and minor neurologic disabilities in surviving twins was 4% and 9%, respectively. MC infants had a higher incidence of cerebral palsy (8% vs 1%, P<.05) and neurologic morbidity (15% vs 3%, P<.05) than DC infants. The risk of impaired neurodevelopment was higher in MC infants with discordant birth weight (42%, P<.01), TTTS (37%, P<.01), and cotwin death (60%, P<.01) than those with concordant birth weight (8%). In MC pregnancies, the cerebral palsy risk was higher in infants with discordant birth weight than those with chronic TTTS (19% vs 4%, P<.05). Similarly, discordant DC infants had higher neuromorbidity than concordant group (5% vs 1%, P<.05). In both MC and DC discordant infants, neurologic morbidity was independent of growth restriction.

CONCLUSION

Neurologic morbidity in the preterm MC infants was 7-fold higher than DC infants because of chronic TTTS, discordant birth weight, and cotwin death in utero.

Thrombophilia and pregnancy

Pregnancy is hypercoagulable state. The field of thrombophilia; the tendency to thrombosis, has been developed rapidly and has been linked to many aspects of pregnancy. It is recently that severe pregnancy complications such as severe preeclampsia intrauterine growth retardation abruptio placentae and stillbirth has been shown to be associated with thrombophilia. Recurrent miscarriage and has also been associated with thrombophilia. Finally, thromboembolism in pregnancy as in the non-pregnant state is linked to thrombophilia. In this review all aspects of thrombophilia in pregnancy are discussed, and also all prophylactic and therapeutic implications.

The influence of fetal loss on the presence of fetal cell microchimerism: A systematic review

OBJECTIVE

Fetal cells enter the maternal circulation during most pregnancies. Their persistence for years occurs in only some women and has been associated with several autoimmune diseases such as systemic sclerosis. The objective of this study was to determine whether pregnancy history influences the persistence of fetal microchimeric cells.

METHODS

We reviewed all reports of studies on fetal cell microchimerism, defined as male DNA in maternal tissue, that describe individual pregnancy histories, disease diagnoses, and microchimerism status. The total numbers of pregnancies, births, and sons, the history of fetal loss (spontaneous abortion and elective termination), and the presence of a maternal autoimmune disease were tested as factors potentially associated with persistent microchimerism.

RESULTS

One hundred twenty-four subjects from 11 studies met the inclusion criteria. Only fetal loss was significantly associated with the presence of microchimerism (odds ratio 2.4, 95% confidence interval 1.2-6.0).

CONCLUSION

These results suggest that fetomaternal cell trafficking following fetal loss may be important for the engraftment of microchimeric cells in maternal tissue. This may be due to an increased amount of fetomaternal transfusion or to transfer of a cell type that is more likely to engraft. We recommend that investigators in future studies on microchimerism report detailed pregnancy information, since these data are critical for the understanding of factors that influence the development of fetal cell microchimerism.

The value of middle cerebral artery peak systolic velocity in the diagnosis of fetal anemia after intrauterine death of one monochorionic twin

OBJECTIVE

The purpose of this study was to assess the value of the fetal middle cerebral artery peak systolic velocity in the prediction of anemia within 24 hours of the death of one monochorionic twin in twin-to-twin-transfusion syndrome and to establish the correlation between middle cerebral artery peak systolic velocity and hemoglobin concentration in fetuses who are at risk for acute anemia.

STUDY DESIGN

Doppler examination of the middle cerebral artery peak systolic velocity was performed in 20 monochorionic survivors of pregnancies that were complicated by twin-to-twin-transfusion syndrome that occurred between 20 and 34 weeks of gestation. Doppler examination was performed before cordocentesis and after intrauterine transfusion when appropriate. Both hemoglobin concentration and middle cerebral artery peak systolic velocity were expressed in multiples of the median. Severe anemia was defined as hemoglobin concentration of <0.55 multiples of the median, and we used the cutoff point of 1.50 times the median values at any gestational age to calculate the sensitivity and specificity of middle cerebral artery peak systolic velocity in detecting moderate or severe anemia.

RESULTS

Fetal anemia was confirmed in 10 of 20 fetuses. We performed seven intrauterine transfusions. The sensitivity and specificity of middle cerebral artery peak systolic velocity in the prediction of severe fetal anemia were of 90%, with a false-negative rate of 10%. The correlation between peak systolic velocity and hemoglobin concentration both before and after transfusion was evaluated by regression analysis and was strongly significant.

CONCLUSION

In fetuses who are at risk of acute anemia, the measurement of middle cerebral artery peak systolic velocity was found to be a reliable noninvasive diagnostic tool and may be helpful in counseling and planning invasive assessment.

Burden of malaria during pregnancy in areas of stable and unstable transmission in Ethiopia during a nonepidemic year

Little is known about the epidemiology of malaria during pregnancy in areas of unstable (epidemic-prone) transmission (UT) in sub-Saharan Africa. In cross-sectional studies, peripheral malaria parasitemia was identified in 10.4% of women attending antenatal care clinics at 1 stable transmission (ST) site and in 1.8% of women at 3 UT sites; parasitemia was associated with anemia in both ST (relative risk [RR], 2.0; P<.001) and UT (RR, 4.4; P<.001) sites. Placental parasitemia was identified more frequently during deliveries at ST sites (12/185; 6.5%) than at UT sites (21/833; 2.5%; P=.006). Placental parasitemia was associated with low birth weight at the ST site (RR, 3.2; P=.01) and prematurity at ST (RR, 2.7; P=.04) and UT (RR, 3.9; P=.01) sites and with a 7-fold increased risk of stillbirths at UT sites. The effectiveness and efficiency in Ethiopia of standard preventive strategies used in high-transmission regions (such as intermittent preventive treatment) may require further evaluation; approaches such as insecticide-treated bednets and epidemic preparedness may be needed to prevent adverse pregnancy outcomes.

Multicystic encephalomalacia

Antepartum death of a fetus in a multiple gestation can be associated with mortality or major morbidity in the survivor. This article reports a rare case of multicystic encephalomalacia that occurred in the survivor twin with antepartum death of its co-twin. Its pathology and pathogenesis are discussed with review of literature.

Long-term neurodevelopmental outcome after intrauterine laser treatment for severe twin-twin transfusion syndrome

OBJECTIVE

The purpose of this study was to investigate long-term neurodevelopmental outcome after intrauterine laser treatment for twin-twin transfusion syndrome.

STUDY DESIGN

All 89 surviving infants who were treated between January 1995 and May 1997 were investigated in a single center. Seventy-five children were tested with the Griffiths' Developmental Test Scales at a median age of 21 months; 14 children (median age, 34 months) were tested with the Snijders-Oomen-Non-Verbal-Intelligence Test. All children underwent a detailed standardized physical and neurologic examination.

RESULTS

Sixty-nine infants (78%) showed a normal development (group I), 10 infants (11%) had minor neurologic deficiencies (group II), and 10 infants (11%) had major neurologic deficiencies (group III). No difference between recipient and donor status was observed (P =.93). There was a trend toward a more favorable outcome for those infants who were born as twins (53 infants [81%] in group I and 5 infants [8%] in group III) compared with singleton survivors after intrauterine death of the cotwin (16 infants [67%] in group I and 5 infants [21%] in group III); however, the difference was not significant (P =.12).

CONCLUSION

After intrauterine laser treatment for twin-twin transfusion syndrome, 78% of the children had a normal neurodevelopmental status, 11% of the children had minor neurologic deficiencies, and 11% of the children had major neurologic deficiencies, at a median age of 22 months.

Anti-shock garment provides resuscitation and haemostasis for obstetric haemorrhage

OBJECTIVE

To evaluate the feasibility, safety and effectiveness of the non-pneumatic anti-shock garment for resuscitation and haemostasis following obstetric haemorrhage resulting in severe shock.

DESIGN

During a six-week period, the author served a locum tenens as the obstetrician consultant for the Memorial Christian Hospital, Sialkot, Pakistan. All women who suffered from severe obstetric haemorrhage were managed with the anti-shock garment as the first intervention. The data for this report were collected from hospital chart review.

SETTING

Sialkot is a city of about three million and Memorial Christian Hospital is one of two major obstetric hospitals. There is no blood bank at Memorial Christian Hospital or elsewhere in Sialkot. The Memorial Christian Hospital laboratory is able to draw donor blood, type and cross match blood, and process it for transfusion 24 hours per day.

POPULATION

During the six weeks of this study, in June and July 2001, there were 764 deliveries and 34 other admissions within a week following deliveries outside the hospital. Seven women with obstetric haemorrhage who developed severe shock were managed with the anti-shock garment. One woman, who was later found to have mitral stenosis, developed dyspnea upon placement of the anti-shock garment and therefore it was removed within 5 minutes. This report concerns the six women who were able to tolerate the anti-shock garment without untoward symptoms.

METHODS

As soon as severe shock was recognised in the hospital, the anti-shock garment was placed. Crystalloid solutions were given intravenously over the first hour at a rate of 1500 mL per estimated litre of blood loss, then at a maintenance rate of 150 mL/hour. Vital signs every 15 to 30 minutes, hourly urine output and intermittent oxygen saturation were used to monitor patients during the use of the anti-shock garment. When sufficient blood transfusion had been given to restore the haemoglobin to >7 g/dL, the anti-shock garment was removed in segments at 15-minute intervals with documentation of vital signs before removal of each subsequent portion.

MAIN OUTCOME MEASURES

Restoration of mean arterial pressure of 70 mmHg and clearing of sensorium were considered as signs of effective resuscitation. Haemorrhage was considered controlled if the blood loss was less than 25 mL/hour. Morbidity included any complications noted in the medical chart.

RESULTS

Restoration of blood pressure and improvement of mental status occurred within 5 minutes in two patients who were pulseless and three who were unconscious or confused. All patients had improvement of mean arterial pressure to greater than 70 mmHg within 5 minutes. Duration of anti-shock garment use ranged from 12 to 36 hours and none of the six women had significant further bleeding while the anti-shock garment was in place. Patients were comfortable during use of the anti-shock garment and no adverse effects were noted apart from a transient decrease in urine output.

CONCLUSIONS

The anti-shock garment rapidly restored vital signs in women with severe obstetric shock. There was no further haemorrhage during or after anti-shock garment use and the women experienced no subsequent morbidity. A prospective randomised study of the anti-shock garment for management of obstetric haemorrhage is needed to further document these observations.

[Delayed delivery of the second twin--a case report]

Delayed interval delivery of the second twin is not a conventional procedure in case of early delivery of the first one. The routine procedure is the provocation of the uterine activity and terminating pregnancy. Patient's willingness to have a desired child presents difficulties for obstetricians and necessitates unconventional steps. The described delivery of the second twin took place in the fifth week after the delivery of the first one. The patient was discharged on the 7th day after caesarean section and the new-born was discharged in good general condition on the 64th day when reaching body weight 3490 gram. Postponing the delivery of the second twin gave time for treatment with glucocorticoids and it prepared the fetus's lungs for extrauterine life. Therapeutically the most essential problem was the prevention of intrauterine infection. The described procedure posing a threat to both mother and foetus gives rise to understandable doubts. Possible risks should be thoroughly discussed with the patient as well as possible future child's problems.

Acquired and inherited thrombophilia in women with unexplained fetal losses

OBJECTIVE

The purpose of this study was to investigate the possible role of inherited and acquired thrombophilia in women with unexplained abortions and intrauterine fetal death.

STUDY DESIGN

We included 75 women with >/=1 unexplained fetal loss, and 75 control subjects with at least 1 healthy term infant and without gestational complications. All of these women were tested for mutations of factor V Leiden, methylenetetrahydrofolate reductase, and prothrombin gene; deficiencies of antithrombin-III, protein C, and protein S; and the presence of antiphospholipid antibodies and fasting homocysteine concentration. A placental histologic study was also carried out.

RESULTS

Thirty-five percent of the 75 patients had thrombophilia (control subjects, 16%; P =.008; odds ratio, 2.78). This prevalence was more prominent in second and third trimesters (P =.0002; odds ratio, 6.3), and the presence of combined genetic defects was associated with intrauterine fetal death (P =.04; odds ratio, 12; 95% CI, 1.44-102). When we analyzed the overall gestations of the patients, we observed an increase of intrauterine fetal death in patients with thrombophilia (P =.01) and early pregnancy loss in patients without thrombophilia (P =.02). The analysis of the correlation between extensive placental infarctions and thrombophilic defects rendered values in the boundaries of significance (P =.05).

CONCLUSION

The significant high prevalence of biologic causes in patients with late fetal loss suggests that a study of thrombophilia should be carried out, together with an assessment of a preventive treatment.

Embolization for advanced abdominal pregnancy with a retained placenta. A case report

BACKGROUND

Abdominal pregnancy is not encountered commonly, and management of the placenta is controversial.

CASE

A 33-year-old woman presented with an abdominal pregnancy at 33 weeks' gestation with fetal death. The placental vasculature was embolized preoperatively. Following operative delivery. of the fetus, the placenta was left in situ in efforts to preserve fertility given its implantation on the reproductive organs. The patient suffered prolonged postoperative ileus but otherwise did well. Placental function ceased after two months.

CONCLUSION

Placental vasculature embolization is a management option for a retained placenta associated with abdominal pregnancy.

Vaginal bleeding patterns among rural highland Bolivian women: relationship to fecundity and fetal loss

Among the most common reasons given for discontinued use of some contraceptive methods is a disturbance in the menstrual cycle, particularly changes in vaginal bleeding. Work to date suggests marked populational variation in menses duration, but few data have been collected from South America. This longitudinal study of non-contracepting Aymara women (n = 189 providing 837 non-truncated bleeding episodes) identified conceptions and fetal loss via urine tests for human chorionic gonadotropin and classified episodes accordingly to test the hypotheses that (a) vaginal bleeding patterns differ between lactating and non-lactating women, (b) duration of vaginal bleeding accompanying fetal loss differs from that of menstruation, (c) menses preceding a conception are longer than those not followed by a conception. Compared to published values, mean menses duration (3.5 days) in these women was relatively short. Menses duration was not significantly correlated with current age, age at menarche or first birth, parity, time postpartum, or menstrual segment length. Mean menses duration (not preceding a conception) was comparable for lactating and non-lactating women. Mean duration of fetal loss bleeding did not differ from that of menses. Pre-conception episodes were significantly longer than those not followed by conception. Thus, because the rate of conceptions was twice as great among lactating than non-lactating women, the mean duration of all menses (irrespective of conception) was significantly longer in lactating women. Bolivian, and perhaps other South American, women may be particularly disinclined to accept contraceptives (e.g., intrauterine devices) that modify an otherwise relatively brief menses duration. Therefore, a wide variety of contraceptive choices accompanied by population-specific informed counseling is essential. In addition, these findings suggest that studies of fecundability limited to non-lactating women may be biased toward those of relatively lower fecundity and that menses duration may be predictive of risk for some cancers.

Disseminated intravascular coagulation

Healthy pregnancy is accompanied by changes in the haemostatic system which convert it into a hypercoagulable state vulnerable to a spectrum of disorders ranging from venous thromboembolism to disseminated intravascular coagulation (DIC). This latter is always a secondary phenomenon triggered by specific disorders such as abruptio placentae and amniotic fluid embolism due to release of thromboplastin intravascularly or endothelial damage resulting from pre-eclampsia and sepsis. In modern obstetric practice the most common cause is haemorrhagic shock with delay in resuscitation leading to endothelial damage. The initial management of massive obstetric haemorrhage is the same whether associated with coagulopathy initially or not. Low-grade DIC, associated with pre-eclampsia, is monitored haematologically by serial platelet counts and serum fibrin degradation products (FDPs). Supportive measures and removal of the triggering mechanism are the key to successful management. Outcome depends primarily on our ability to deal with the trigger and not on direct attempts to correct the coagulation deficit.

Adverse perinatal outcome of twin pregnancies according to chorionicity: review of the literature

Twin gestations are at significant increased risk for adverse perinatal outcome. As a result, although prospective randomized data is lacking, increased fetal surveillance has been advocated for twins. Growth concordance is considered a reassuring sign in twins and conversely, discordancy to possibly reflect a hostile intrauterine environment at least to the smaller twin. Consequently, increased surveillance of discordant twins is commonly practiced. Monochorionic twins are at further risk for type-specific perinatal complications, for example, twin-twin transfusion syndrome. Recently, precise first-trimester depiction of chorionicity has enabled early antepartum stratification of twin gestations according to chorionicity, in comparison with previous later (mid- and third-trimester) ultrasonographic diagnosis of chorionicity. This immediately leads to the question whether antenatal testing of twins should differ according to chorionicity? Review of the literature supports that despite the existence of complications unique to monochorionic twin gestations, dichorionic twins sustain an increased risk of adverse perinatal outcome (such as fetal growth restriction) in comparison with singletons, and that close antenatal fetal surveillance of twins should be performed, irrespective of chorionicity.

Aplasia cutis congenita in an infant of an initial triplet gestation: a case report

Aplasia cutis congenita (ACC) is the clinical manifestation of an uncommon group of skin disorders. One postulated etiology is disseminated intravascular coagulation from release of thrombogenic maternal arising from placental injury or fetal demise. This leads to disruption of the ectodermal blood supply responsible for the skin defects. We present a neonate with group V ACC, one of an initial triplet gestation, associated with fetal demise at 14 weeks and formation of a fetus papyraceus. The practice of selective fetal reduction as a result of multiple gestation seen with the use of fertility drugs may in theory increase the incidence of group V ACC.

First presentation of polymyositis postpartum following intrauterine fetal death

We present a case of polymyositis (PM) following intrauterine fetal death. The first presentation of PM in the patient was during postpartum. The patient was referred to our hospital because of a fever of unknown cause 13 d after delivery of dead fetus at 32 weeks' gestation. PM was diagnosed based on the increased serum creatine phosphokinase level, typical electromyogram findings and characteristic muscle biopsy findings.

Parental origin and phenotype of triploidy in spontaneous abortions: predominance of diandry and association with the partial hydatidiform mole

The origin of human triploidy is controversial. Early cytogenetic studies found the majority of cases to be paternal in origin; however, recent molecular analyses have challenged these findings, suggesting that digynic triploidy is the most common source of triploidy. To resolve this dispute, we examined 91 cases of human triploid spontaneous abortions to (1) determine the mechanism of origin of the additional haploid set, and (2) assess the effect of origin on the phenotype of the conceptus. Our results indicate that the majority of cases were diandric in origin because of dispermy, whereas the maternally-derived cases mainly originated through errors in meiosis II. Furthermore, our results indicate a complex relationship between phenotype and parental origin: paternally-derived cases predominate among "typical" spontaneous abortions, whereas maternally-derived cases are associated with either early embryonic demise or with relatively late demise involving a well-formed fetus. As the cytogenetic studies relied on analyses of the former type of material and the molecular studies on the latter sources, the discrepancies between the data sets are explained by differences in ascertainment. In studies correlating the origin of the extra haploid set with histological phenotype, we observed an association between paternal-but not maternal-triploidy and the development of partial hydatidiform moles. However, only a proportion of paternally derived cases developed a partial molar phenotype, indicating that the mere presence of two paternal genomes is not sufficient for molar development.

Maternal cocaine abuse and fetal renal arteries: a morphometric study

The purpose of the present study was to evaluate the pathological findings and perform morphometric analysis of the renal arteries of fetuses exposed to cocaine in utero. The control group consisted of 22 stillborn fetuses of unknown etiology whose mothers' urine was negative for cocaine or any other vasoactive substances. The study group comprised 29 stillborn fetuses whose mothers' urine was positive only for cocaine on the day of admission. Sections of fetal kidneys (4 microm), stained with hematoxylin and eosin and periodic acid-Schiff reagent, were examined under light microscopy (x40) to identify interlobular arteries. Morphometric analysis of these arteries was performed using a self-assembled system with a touch-sensitive screen as an interactive peripheral. Their inner and outer circumferences were measured by outlining them on the screen with a stylus. The radius (r) was calculated from the measurement of the circumference (2.pi.r). The difference of the radii of the outer and inner circumferences was the thickness of the arterial wall. The interlobular arterial thickness was significantly greater (P<0.001) in the cocaine-exposed group (mean 15.46+/-5.8 microm, 2SD) compared with the normal (mean 9.03+/-3.96 microm, 2SD). There was a significantly (P<0.001) positive relation with advancing gestational ages in both groups. The circumferences of the lumen of the arteries showed a significant (P<0.05) relation with advancing gestational ages in the normal group only. In the cocaine-exposed group, the arterial lumen circumference (mean 167.88+/-17.58 microm, 2SD) was significantly (P<0.001) smaller than in the normal group (mean 227.73+/-6.82 microm, 2SD). Thus, maternal cocaine abuse is associated with thickening of the interlobular arterial wall of the fetal kidney and narrowing of the lumen.

Clinical features and management of 87 patients with pemphigoid gestationis

Pemphigoid gestationis is a rare vesiculo-bullous disorder of pregnancy. In this review we summarize the clinical data on 142 pregnancies in 87 patients complicated by pemphigoid gestationis. Our aim is to provide a comprehensive clinical overview of this disease.

Rapid development of hydrops fetalis in the donor twin following death of the recipient twin in twin-twin transfusion syndrome

Intrauterine death of one fetus in monochorionic twinning is associated with high rates of perinatal morbidity and mortality in the surviving fetus. Subsequent development of hydrops fetalis in the donor twin after fetal demise of the recipient twin has been described in only two case reports and pathophysiology remains unclear. We report on a monochorionic-diamniotic twin pregnancy complicated by severe twin-twin transfusion syndrome. Ultrasound examination at 20 weeks of gestation showed discrepant twins with oligohydramnios in the smaller twins' sac and polyhydramnios in that of the larger twin. Repeated amniocenteses permitted prolongation of the pregnancy. However, the recipient twin developed deteriorating hydrops fetalis and died at 28 weeks of gestation. After this event, subsequent development of hydrops fetalis in the surviving donor twin could be observed, as well as an increase of amniotic fluid. An elective cesarean section was performed at 29 weeks of gestation. Initial hypoxemia could be effectively treated by high frequency oscillatory ventilation, surfactant therapy and inotropic support. The infant was discharged in good condition at the age of 2 months. Although rare, antenatal demise of the recipient twin in a monochorionic pregnancy can be associated with the subsequent development of hydrops fetalis in the surviving donor twin. We speculate that this phenomenon is due to ischemia-reperfusion injury of the previously poorly perfused twin.

Intrauterine growth restriction is associated with persistent juxtamedullary expression of renin in the fetal kidney

BACKGROUND

Intrauterine growth restriction (IUGR) has been linked to impaired renal function and hypertension, suggesting that an adverse prenatal environment could alter kidney development and renin production.

METHODS

Immunohistochemistry and in situ hybridization were employed to localize renin-containing cells (RCCs) in the deep, middle, and superficial zones of autopsy kidney sections, in parallel with histologic maturation, from unexplained stillborn fetuses of normal weight (N = 26) and stillborn fetuses with IUGR (N = 17).

RESULTS

In the control group, the number of RCC per 100 glomeruli in the deep zone decreased with advancing gestation from 40 at 20 weeks gestation to five at term (P < 0.001), whereas the opposite change was found in the superficial zone (increase from 5 per 100 to 55 per 100; P < 0.001). In the IUGR group, the density of RCCs in both the superficial and deep zones was similar to the control group at 20 weeks, and no shift in renin gene expression was observed as gestation advanced. Histologic maturation was unaltered.

CONCLUSIONS

Renin gene expression persists and predominates in the deep renal cortex of the stillborn IUGR fetus, and could contribute to the pathogenesis of neonatal oliguria and/or hypertension during postnatal life.

Abruptio placentae: risk factors and perinatal outcome

OBJECTIVE

It is a case control study, conducted in order to determine the risk factors, and to find out the perinatal outcome of abruptio placentae in women delivered at the Princess Badeea Teaching Hospital in North Jordan.

METHODS

We reviewed all cases of placental abruption delivered between 15th April 1994 till 26 November 1995 and to compare that with pregnancies and deliveries not complicated by abruptio placentae.

RESULTS

During the study period there were 108 cases of abruptio placentae and 108 cases of the control group. The total number of women delivered were 18,256, so the incidence of abruptio placentae was 5.9 per 1000 births. When compared to the control group, abruptio placentae occurred more in parous women (para > or = 5) (p < 0.0005), more preterm deliveries (p < 0.0001) with more birth weight < 2,500 g (p < 0.0001). Preeclampsia and pregnancy induced hypertension, intrauterine growth retardation, caesarean delivery, and intrauterine fetal death occurred more in patients with abruptio placentae.

CONCLUSION

High parity, preeclampsia and hypertension are significant etiological determinants of abruptio placentae.

Antenatal diagnosis of brain damage in the survivor after the second trimester death of a monochorionic monoamniotic co-twin: case report and literature review

At 28 weeks of amenorrhea, 1 fetus of a monoamniotic twin pregnancy died. Ultrasound and Doppler investigations of the surviving twin were normal. Three weeks later, endovaginal ultrasound and magnetic resonance imaging revealed massive bilateral cerebral ischemic necrosis in the surviving twin. In utero fetal blood sampling carried out before the termination did not reveal either anemia or thrombopenia. Current data suggest that cerebral or renal ischemic complications could set in immediately after the death of the first twin as a result of a period of acute hypotension. At least 2 weeks are necessary for them to be identifiable by ultrasound. It seems that they cannot be prevented by prompt delivery of the second twin.

Antibodies to thromboplastin in systemic lupus erythematosus: isotype distribution and clinical significance in a series of 92 patients

We determined the prevalence and relationship with clinical manifestations of antibodies to thromboplastin (aTP) in 92 patients with systemic lupus erythematosus (SLE). Thirty-two (35%) patients had aTP: 13 (14%) were positive for IgG aTP, 13 (14%) for IgM aTP, and 6 (7%) for both. Patients with aTP had an increased incidence of thrombosis (p = 0.01), thrombocytopenia (p < 0.001), hemolytic anemia (p < 0.001), and fetal losses (p = 0.03). When the IgG and IgM aTP isotypes were analysed separately, the IgG aTP were found to be associated with thrombosis (p < 0.001), thrombocytopenia (p < 0.001), and fetal losses (p = 0.02). The IgM aTP were associated with hemolytic anemia (p < 0.001). A correlation was found between the titers of aTP and those of anticardiolipin antibodies, in both IgG (p < 0.01, r = 0.6) and IgM (p < 0.01, r = 0.64) isotypes, and between the titers of IgG aTP and the diluted Russell's viper venom time used to detect the lupus anticoagulant (p < 0.001, r = 0.42). This test is a reliable, reproducible and sensitive assay for the detection of antiphospholipid antibodies, specially in those patients under anticoagulant therapy.

[Intra-uterine fetal death syndrome--not only a gynecologic problem]

Intra-uterine fetal death may seriously affect maternal health and implies considerable risk of maternal death, especially when clotting and septic disorders arise. Management od IUFD should include removal of the triggering mechanism for DIC, antiinfectious prophylaxis and consider prompt evacuation of uterus. Low-dose heparin therapy is safe and offers sufficient protection against coagulopathy associated with IUFD. Treatment with low-dose aspirin, steroids or substitutive ACTH therapy is useful for patients with a poor obstetrical outcome. Etiopathology of IUFD, complications, methods terminating of the pregnancies has also been presented.

Hepatitis C virus infection in pregnancy and the risk of mother-to-child transmission

The risk of vertical transmission of the hepatitis C virus (HCV) from infected mothers to their children during pregnancy and delivery was determined in 120 children born to HCV-positive mothers. Methods included enzyme immunoassay and immunoblot for detection of HCV antibodies and reverse transcription polymerase chain reaction (RT-PCR) for detection of viral RNA. Six (5%) children were perinatally infected with HCV as shown by RT-PCR. None of the infected children had clinical signs of hepatitis. None of the pregnancies was complicated by abortion, stillbirth, premature birth, or malformation of the child. Special concern was given to the possibility of HCV transmission via breast milk. In no breast milk sample obtained from 34 HCV-infected mothers was HCV RNA detected. These observations indicate that HCV infection is not necessarily a contraindication for breast-feeding.

Prevalence of coagulation abnormalities associated with intrauterine fetal death

PURPOSE

The purpose of this study was to determine factors associated with abnormal coagulation in the setting of intrauterine fetal death (IUFD).

METHODS

We reviewed the charts of 238 patients diagnosed with IUFD over ten years. Data included demographics, co-existing obstetric disease and coagulation studies. A coagulation score was assigned based on the platelet count, prothrombin time, activated partial thromboplastin time and plasma fibrinogen concentration. Approximately 90% of the study population had coagulation scores < 4. A score of > or = 4 was considered abnormal.

RESULTS

Complete coagulation analysis was available in 183/238 patients (77%) within 24 hr of delivery. One hundred and sixty-four of these (89.6%) had a coagulation score, < 4 and 19 had a score > or = 4 (10.4%). No relationship between the coagulation score and age, parity, gestational age at delivery, and number of days the dead fetus remained in utero was found. A coagulation score > = or 4 was associated with the presence of a pregnancy-related disease (P < 0.05), notably abruption (P < 0.001) and uterine perforation (P < 0.05). Four patients without co-existing disease (3.2%), had a coagulation score > or = 4.

CONCLUSION

In most pregnancies complicated by fetal demise, the fetus and placenta are delivered within one week of fetal demise. The previously reported severe coagulation disturbances are largely eliminated by early delivery. Our study shows that coagulation abnormalities occur in some patients with uncomplicated IUFDs (3.2%) and that this number rises in the presence of abruption or uterine perforation.

Inflammation of the lungs, umbilical cord and placenta associated with meconium passage in utero. Review of 123 autopsied cases

It is uncertain how often the passage of meconium in utero is a response to some event causing fetal distress as opposed to being simply the physiologic functioning of a maturing intestinal tract. The extent to which meconium may produce injury or inflammation in pulmonary and placental tissues after intrauterine exposure is also unclear. This study was a retrospective review of 123 cases, 79 stillborn and 44 liveborn less than one month of age, autopsied at The Johns Hopkins Hospital, and showing histologic evidence of intrauterine meconium exposure by aspirated meconium or meconium macrophages in placental tissues. Of 55 cases with pulmonary inflammation, 13 (24%) had fetal pneumonia, 5 (9%) had postnatal bronchopneumonia, and 37 (67%) had inflammation secondary to meconium aspiration. There was inflammation of the umbilical cord in 31 (41%) of the 75 cases with available slides, 11 (15%) had funisitis associated with chorioamnionitis and 18 (58%) were secondary to meconium exposure. There were 19 cases with focal injury of cord vessels from meconium, two of which had cord ulceration. Inflammation of the membranes and chorionic plate was present in 24 (33%) of the 72 cases where it could be assessed, and was due to chorioamnionitis in 11 (46%) and to meconium in 13 (54%). In general, meconium-related inflammations was much less severe in the membranes than in the cord. There were 67 (54%) cases with definite or probable evidence of fetal distress. In 38 (48%) stillborns no cause of fetal death in utero was identified and in 18 (41%) liveborns there was no known prenatal problem. The results support the concept that meconium passage in utero may occur either as a response to fetal distress or as a physiologic process. Inflammation in the lung and placental tissues, and vascular injury in the umbilical cord may arise secondary to in utero exposure to meconium.

Congenital diaphragmatic hernia: can prenatal ultrasonography predict outcome?

OBJECTIVE

We wanted to establish whether prenatal ultrasonography predicts postnatal outcome in congenital diaphragmatic hernia.

STUDY DESIGN

We designed a retrospective multicenter cohort study of 135 patients with congenital diaphragmatic hernia (122 left, 10 right, 2 bilateral, 1 anterior). In isolated left congenital diaphragmatic hernia five potential prenatal prognostic factors were studied: diagnosis at < or = 25 weeks' gestation, polyhydramnios, intrathoracic stomach, small abdomen, and major mediastinal shift.

RESULTS

None of the 44 fetuses or infants who had multiple malformations survived. Of the 91 cases of isolated congenital diaphragmatic hernia, there were 82 live births; 76 of these infants had a left congenital diaphragmatic hernia. Of these, 51 (67%) died postnatally. A statistically significant relation was found between mortality and polyhydramnios, intrathoracic stomach, and major mediastinal shift. Mortality increased as a function of the number of these prognostic factors from 20% when none was present to 94% when all three were present.

CONCLUSION

In the majority of cases of isolated left congenital diaphragmatic hernia the prognostic value of fetal ultrasonography is too low to alter perinatal management.

The prevalence of non-viable pregnancy at 10-13 weeks of gestation

In an ultrasound screening study at 10-13 weeks of gestation involving 17,870 women, the prevalence of early pregnancy failure was 2.8% (501 cases), including 313 (62.5%) missed abortions and 188 (37.5%) anembryonic pregnancies. Lower gestation and higher maternal age were associated with a higher prevalence (chi 2 = 143.5; p < 0.001 and chi 2 = 53.3; p < 0.0001, respectively). The prevalence was higher in women with a history of vaginal bleeding (chi 2 = 141.5; p < 0.0001), but there was no significant association with previous pregnancy losses (chi 2 = 2.8), parity (chi 2 = 0.6) or cigarette smoking (chi 2 = 0.0). Recent evidence suggests that the most effective method of screening for chromosomal abnormalities is measurement of fetal nuchal translucency thickness at 10-13 weeks, and therefore ultrasound examination at this gestation is likely to become universally available. As shown in this study, an additional advantage of such a scan is the diagnosis of early pregnancy failure, which will be found in about 3% of patients examined. Elective evacuation of retained products of conception is likely to be more cost effective and potentially safer than emergency surgery in a patient presenting during miscarriage.

Congenital bilateral perisylvian syndrome in a monozygotic twin with intra-uterine death of the co-twin

Congenital bilateral perisylvian syndrome was diagnosed in a two-year- old boy with signs of pseudobulbar and diplegic cerebral palsy presenting on MRI a polymicrogyric appearance of the perisylvian regions. He was born from a monochorionic bi-amniotic twin pregnancy complicated by twin-twin transfusion syndrome and death of the co-twin between the 16th and 18th weeks of gestation. Ventricular enlargement and hepatic hyperechogenic lesions were seen during his sonographic intra-uterine follow-up. The authors suggest that ischaemic injury occurred in this patient as a consequence of acute haemodynamic changes induced by the death of his co-twin.

Pregnancy and nursing

The IBD patient should be optimistic about a potential pregnancy. Inactive IBD is not associated with decreased fertility. Inactive IBD does not affect the course of pregnancy; however, IBD has been associated with increased preterm deliveries. Active IBD during pregnancy is associated with increased stillbirths and spontaneous abortions but not with increased congenital abnormalities. Pregnancy does not cause exacerbation of previously quiescent IBD. If the disease is active at conception, it remains active or worsens in approximately two thirds of patients. Corticosteroids, sulfasalazine, and 5-ASA drugs are safe and should be used to maintain or induce remission. Antimetabolites may possibly be proved safe in the future during pregnancy but cannot yet be recommended. Both enteral nutrition and total parenteral nutrition can and should be used safely and effectively during pregnancy. Radiographs are to be used in diagnosis if an emergent condition, such as perforation or toxic megacolon, is suspected. The chance of an offspring developing IBD is about 9% but rises to 34% if both parents have IBD.

Premature centromere division: a possible manifestation of chromosome instability

Retrospective analysis of "routine" chromosome preparations from 2 patients with Fanconi anemia and 2 others with ataxia-teleangiectasia showed increased chromosome breakage and a tendency to premature centromere division (PCD) with special reference to early separation of the large acrocentric (13-15) chromosomes. The findings suggest that PCD may be a manifestation of chromosome instability related to potential malignancy.

Monofetal death in multiple pregnancies: risks for the co-twin, risk factors and obstetrical management

The intrauterine death of one fetus in the case of multiple pregnancies can have an impact on the development of the surviving twin. Based on a single-centre retrospective personal study of 248 multiple pregnancies, 10 of which presented a monofetal intrauterine death, the authors observed the type of placentation, the age and cause of the death, the way in which pregnancy continued and the outcome of the surviving twin. This investigation also includes a review of published documents. Monochorial pregnancies were more frequently encountered in the case of monofetal death in utero. The etiology of the death was not always found and one surviving twin presented lesions as microcephaly convulsions and was retarded on a psychomotor level. In this series these complications did not exist when the pregnancy was bichorial. The authors conclude by demonstrating the major risk of fetal contamination for a live twin coexisting with a dead twin in the case on monochorial pregnancy. Other parameters (cause of death, gestational age at death, delay and duration of cohabitation), do not seem to be significant. It would appear to be of fundamental importance to establish an accurate diagnosis of placentation and to implement specific surveillance of monochorial pregnancies. A decision tree is suggested for use in the case of monofetal death.

Overwhelming maternal sepsis due to a gas-forming Escherichia coli chorioamnionitis

We report a case of a patient who developed fulminant sepsis and respiratory distress caused by a gas-forming Escherichia coli intrauterine infection following premature rupture of the membranes and fetal death. Such gas-forming infections are rare, and, when they occur, they are usually caused by Clostridium welchii. This patient was treated with antibiotics, ventilator support, and hysterectomy, and at follow-up was in good health.