Volume 29, Issue 2

Cancers in pregnancy are uncommon but do occur with an average frequency of 1 in 1,000 births. This gives rise to opposing emotional reactions in these women: they are happy they are pregnant, but usually devastated when they hear they have cancer. The major reasons for suspecting that pregnancy adversely affects the clinical course of cancer is the immunologic tolerance that characterizes both conditions. It has been pointed out that normal pregnancy and cancer are the only two biologic conditions in which the antigenic tissues is tolerated by a seemingly intact system. It may be stated that the mechanisms that insure the survival of fetus during pregnancy presumably also favors the progress of the neoplasia. Management requires individualization with careful thought as whether termination is necessary or whether continuing with the pregnancy is possible prior to definitive treatment. The physician's aim must be to cure the cancer and deliver live, healthy infants. This is one question when a joint decision is probably best reached among the obstetrician, surgical and medical oncologists and other disciplines. The life-threatening cancer should be managed both for the diagnosis and treatment as in the non-pregnant state. An early small cancer gives a better prognosis than an advanced cancer. The same holds for the non-pregnant patient. The survival in the non-pregnant patient stage for stage is the same as for the pregnant patient. However, all too often in the pregnant state the cancer is more advanced than in the non-pregnant patient. The disease must be evaluated and treated in full light of its exact location in conjunction with an understanding of the natural history within the context of the pregnancy with the potentially viable unborn infant. Concern that maternal cancer may metastasize to the fetus is not justified from a review of the accumulated literature. Infrequency of fetal involvement has led to speculation about biologic protective mechanisms that may exist for the placenta and the fetus and the role circulatory separation in the placenta and immunologic responses of the fetus may play. The association of cancer in pregnancy represents a major physiologic process for the maintenance of the race and a major pathologic process that accounts for numerous deaths. It presents a controlled growth and an uncontrolled growth in the same host.

Introduction: Recent studies in sheep have shown that repeated maternal injections of betamethasone are associated with adverse effects within the nervous system. Repeated fetal injections of betamethasone achieve serial improvements in preterm lung function in sheep and are a possible alternative to repeated maternal therapy. We have evaluated the effect of repeated fetal administration of betamethasone on nervous system maturation in an ovine model. Methods: Date-mated ewes (n = 48) were randomized to receive ultrasound-guided fetal injections of betamethasone or saline between days 104 to 124 of gestation and were delivered by cesarean section on day 125 or 145 (term = 150). Optic and sciatic nerves were pre- pared for light and electronmicroscopy. Eye diameters were measured and transverse sections of retinae were evaluated. Data were analyzed using a mixed model analysis of variance. Results: Repeated fetal administration of corticosteroid did not significantly affect optic nerve myelination but resulted in significant delays in sciatic axonal growth (p < 0.02) and retinal maturation (p < 0.04). The process of performing repeated fetal injections also significantly affected some retinal parameters. Conclusion: Repeated fetal administration of betamethasone alters some aspects of nervous system maturation in sheep. It is premature to plan trials of repeated fetal corticosteroid therapy in humans.

Objective : To compare the incidence of twin births and their birth weight characteristics in mothers aged ≥ 40 years with those of mothers aged 35–39 years. Methods: We used a population-based cohort of Israeli twins delivered between 1993–98 to compare birth weight characteristics of 510 and 2102 twin pairs delivered to mothers aged ≥ 40 years (cases) and 35–39 years (controls), respectively. Results: The incidence of twin mothers aged 40 years or more increased 50% during the study period, ten times more than mothers aged 35–39. There were significantly more nulliparas (P < .001, OR 1.54, 95% CI 1.2, 1.9) and more para ≥ 4 (P< .004, OR 1.38, 95% CI 1.1, 1.7) among older mothers. Irrespective of parity, there were no significant differences between mean twin birth weight, total twin birth weight < 3000 g, 3000–4999 g, and ≥ 5000 g, and frequencies of very low birth weight neonates. Conclusions: Twin birth at the age of ≥ 40 years is significantly more likely among either nulliparas or para ≥ 4. Birth weight characteristics of twins delivered to mothers aged ≥ 40 years are not different from those delivered to 35–39 years old mothers.

Objective: The 70 kilo Dalton heat shock protein is upregulated when cells are under physiological stress. It prevents protein denaturation and incorrect polypeptide assembly, and inhibits apoptosis as well as the transcription of genes coding for pro-inflammatory cytokines. To evaluate if up-regulation of heat shock protein 70 can occur during pregnancy, we examined whether addition of bacterial lipopolysaccharide to human amniochorion membranes in vitro stimulated heat shock protein 70 gene transcription. Materials and methods: Amniochorionic membranes (n = 5), collected at the time of elective repeat cesarean section prior to labor from normal term gestations, were placed in an organ explant system. After 48 hour in culture, the membranes were stimulated with lipopolysaccharide for 24 hours. Total RNA was extracted and subjected to an oligo dT primed reverse transcriptase reaction followed by polymerase chain reaction (PCR) using heat shock protein 70 specific primers. PCR products were hybridized with biotinylated internal probes and identified by enzyme-linked immunosorbent assay (ELISA). Results were analyzed by Mann-Whitney U test. A p < 0.05 was significant. Results: Heat shock protein 70 messenger RNA was expressed by all fetal membrane preparations both prior to and following in vitro culture. Addition of lipopolysaccharide increased the concentrations of heat shock protein 70 messenger RNA in each sample tested from a mean of 35.5 ± 29.6 ng/milliliter (12.1–80.1 ng/milliliter) to 169.6 ± 69.9 ng/ml (51.7–218.2 ng/milliliter) (p = 0.03). Conclusion: Human fetal membranes constitutively express heat shock protein 70 messenger ribonucleic acid. Bacterial lipopolysaccharide markedly stimulated heat shock protein 70 messenger RNA gene transcription in human fetal membranes. Thus, heat shock protein 70 is inducible in fetal membranes and may facilitate fetal survival under adverse conditions.

Positive end expiratory pressure is routinely used when ventilating preterm infants. Elevation of PEEP increases lung volume, as does surfactant treatment. The purpose of this study was to investigate the effect of various levels of PEEP within the range of 0.2 to 0.4 kPa on lung volume, compliance and gas exchange. We measured functional residual capacity, compliance of the respiratory system and arterial blood gases in 20 infants (median birth weight 1240 g, range 660–1690 g; median gestational age 28 weeks, range 24–32 weeks; postnatal age 3–4 days). The infants were studied at 72 hours after their last dose of natural surfactant. At this time the patients were routinely nursed at 0.3 kPa of PEEP, the PEEP level was lowered to 0.2 kPa or raised to 0.4 kPa in random order. The PEEP level was then changed to the third level 0.4 kPa or 0.2 kPa. Each new setting was maintained for 20 min before FRC, compliance and blood gases were measured. FRC was assessed using SF6 washout technique. Increasing PEEP from 0.2 to 0.3 to 0.4 kPa resulted in increases in FRC (p < 0.01) and oxygenation (ns) in all infants. In 16 infants compliance decreased and paCO 2 increased with elevation of PEEP. Only in 4 infants compliance increased and CO 2 fell. Conclusion: In the majority of our infants reduction of PEEP from 0.4 to 0.2 kPa resulted in increases in compliance and CO 2 reduction. Our results might suggest that relatively low levels of PEEP < 0.3 kPa may be appropriate at 72 hours after surfactant replacement. Furthermore, these results underline the importance of PEEP test in clinical practice.

We counted nucleated red blood cells (NRBC) per 100 white blood cells (WBC) in the umbilical cord blood from 98 twins born to 49 women with uncomplicated twin pregnancies at ≥ 34 weeks of gestation to better characterize NRBC in twins. Twelve women with monochorionic (MC) placentas and 37 with dichorionic (DC) placentas gave birth at 36.7 ± .9 and 36.5 ± 2 weeks of gestation, respectively. All twins were born with an Apgar score of ≥ 7 at 1 min. Log 10 (NRBC/100 BC) in 98 twins exhibited a nearly normal distribution, and was significantly associated with gestational age for both MC (r=−0.457, p = 0.025) and DC twins (r =−0.275, p = 0.018), and with birth weight for both MC (r=−0.682, p < 0.001) and DC twins (r=−0.336, p = 0.003). Log 10 (NRBC/100 WBC) tended to be larger in smaller twins than in larger twins in the MC group, and significantly larger in smaller twins than in larger twins in the DC group (p < 0.05). Intertwin difference in Log 10 (NRBC/100 WBC) was defined as the value of Log 10 (NRBC/100 WBC) of the smaller twin minus Log 10 (NRBC/100 WBC) of the larger twin, and became greater with increasing intertwin difference in birth weight (r = 0.411, p = 0.003). These findings suggest that neonatal NRBC reflected gestational age and birth weight in twins. This preliminary observation using a small number of twins suggests that the smaller twin may have experienced a relative lack of oxygen compared with the larger twin in utero.

Doppler recordings of fetal venous blood flow seem to be superior to arterial velocimetry and CTG concerning the prediction of fetal outcome and optimal time of delivery in pregnancies with fetal growth retardation and AREDV. An improvement of arterial Doppler flow velocities has been described. We report the reappearance of a normal end-diastolic flow velocity in a ductus venosus temporarily showing reversed end-diastolic flow in a growth-retarded fetus with congenital anomalies. This normalization was accompanied by an improvement of the CTG, a loss of umbilical vein pulsations, a reappearance of umbilical diastolic flow and a progressive return of cerebral and venous blood flow into the ‘normal’ range. Improvement of fetal condition may be the explanation for our observation.

Background: Postthrombotic syndrome is an important late complication after deep vein thrombosis in pregnancy. Thrombolytic agents are more efficient in preventing this condition but are rarely used in pregnant women. Case: A 22-year-old woman at 29 weeks of gestation presented with acute iliac vein thrombosis. After application of a heparin bolus, systemic streptokinase lysis was performed. Low-dose heparin therapy was continued for the remainder of the, otherwise unremarkable, pregnancy. Spontaneous delivery of a healthy girl was without complications and thromboprophylaxis with low-molecular heparin was continued. Conclusion: Thrombolysis in pregnancy is possible and may help to prevent severe long-term sequelae of thrombosis in young women. Bleeding is a major risk, which must be considered and therapy should only be administered under close observation.

We present the case of a full term infant affected by diffuse persistent interstitial pulmonary emphysema (PIPE), who was treated with partial liquid ventilation (PLV) after the failure of conventional management. PIPE is a lethal chronic lung disease of unclear pathogenesis. Clinical history, radiological and histological findings confirmed the diagnosis in our patient. PLV applied for 48 hours resulted in a significant improvement in the infant's respiratory function and was not associated with adverse effects. We concluded that PLV could be effective in prolonging the survival of infants with PIPE; its application represents an effective form of respiratory support in infants with chronic lung disease.

Environmental and genetic risk factors interact to cause venous thromboembolism. Renal vein thrombosis in the newborn has been frequently associated with “risk factors” as catheters, surgery or trauma, but it has also been demonstrated a pathogenetic role of genetic prothrombotic risk factors, i. e. activated protein C resistance and FV Leiden. The treatment of neonatal venous thrombosis varies worldwide and different approaches have been proposed. We present a case of renal vein thrombosis in a female newborn with normal plasma levels of protein C, protein S and antithrombin III, but with her genotype characterized by the presence of three prothrombotic risk factors: factor V Leiden, methylentetrahydrofolate reductase and platelet glycoprotein IIIa polymorphisms. The treatment with recombinant tissue plasminogen determined complete thrombus dissolution.