Volume 32, Issue 2

A large placental chorioangioma is a relatively rare condition, which in 50% of all cases will lead to maternal and fetal complications. Since chorioangiomas are often associated with significant arterio-venous shunting within the placenta, several fetal hemodynamic compensatory mechanisms are initiated. Ultrasound and color Doppler flow mapping are important for the prenatal diagnosis of chorioangiomas, as an early prenatal diagnosis is crucial to minimize the risks for fetal well-being. Close surveillance of pregnancy and pregnancy termination by cesarean section at the earliest signs of fetal cardiac decompensation are indicated to reduce fetal and neonatal complications. Novel intrauterine treatment options include intravascular transfusion, fetoscopic devascularization, microcoil embolization, and intravascular injection of absolute alcohol.

We analyzed a cohort of 2850 live-born triplet sets to compare age, parity, stature, pre-gravid body mass index (BMI), and weekly weight gain in mothers who delivered triplets with a total weight in the 10th, 5th, and 1st deciles corresponding to the heaviest, average-weight, and lightest triplet sets, respectively. Mothers who delivered the heaviest triplets were significantly older, multiparous, taller, heavily built, and gained more weight compared with mothers of average-weight triplets. In contrast, except for higher parity, mothers of average-weight sets were not significantly different compared with mothers who delivered the lightest triplet sets. We concluded that parity was the only significant factor for increased total triplet weight in the first five deciles. However, the presence of other factors in addition to parity is needed for a triplet pregnancy to be included in the 10th decile.

Objective: Polyhydramnios places increased tension on the fetal membranes and should conceptually be associated with an increased need for tissue remodeling to prevent premature rupture of membranes (PROM). Herein we use polyhydramnios as a model to study the association of the collagenase class of matrix metalloproteinases (MMPs) with tissue remodeling during pregnancy. Methods: Amniotic fluids were collected by transabdominal amniocentesis from women with polyhydramnios and from women with normal amniotic fluid volume at second trimester, third trimester and at term. Fluids were assayed for MMP-1 and MMP-13 (collagenase-1 and 3) using ELISA. The concentrations in polyhydramnios were compared with subjects undergoing amniocentesis with normal amniotic fluid volume. Statistical comparisons were made using Scheffe's method for correction in multiple means comparison. P of <0.05 was considered statistically significant. Results: MMP-1 and MMP-13 are present in the amniotic fluid at all stages of pregnancy. The concentrations of these MMPs were significantly elevated in the polyhydramnios samples independent of gestational age. Conclusion: Polyhydramnios is associated with increased amniotic fluid concentrations of MMP-1 and MMP-13 suggesting their role in tissue remodeling.

Background: Thrombin possesses potent oxytocic activity in vitro and in vivo . This activity has been proposed to play a role in post-parturitional uterine contractions and possibly, preterm birth related to intrauterine hemorrhage. Previous workers have demonstrated that cyclo-oxygenase pathway may not play a significant role in oxytocic activity of thrombin. However, the role of 5-hydroxytryptamine (a mediator of some of the biological activities of thrombin) in the oxytocic activity of thrombin is unknown. The present study therefore aimed to examine the possible involvement of 5-hydroxytryptamine in thrombin-induced myometrial contractions. Methods: Effect of 5-hydroxytryptamine receptor antagonists on thrombin-induced contractions of isolated gravid rat myometrium was studied using isolated tissue bath system. Results: Thrombin-induced myometrial contractions were significantly and concentration-dependently inhibited by ketanserin and methysergide. Furthermore, 12±2% increase in the force of contractions of gravid rat myometrium pre-contracted with 5-hydroxytryptamine (1 μM) was provoked by 1 U/ml of thrombin. Thrombin-induced augmentation of the uterine stimulating effect of 5-hydroxytryptamine was characterized by pronounced increase in the contractile tone. Conclusions: 5-hydroxytryptamine may possibly play a role in oxytocic activity of thrombin. Uterine hyperactivity associated with intrauterine hemorrhage could hence involve thrombin-induced 5-hydroxytryptamine production in the uterus.

Objectives: To assess by two- and three-dimensional ultrasound the diameter and volume of the yolk sac in pregnant women affected by type 1 diabetes during the first trimester of pregnancy. Methods: 18 women affected by insulin-dependent diabetes mellitus (IDDM) and 52 normoglycemic pregnant women (controls) were enrolled in this study. The women were evaluated once a week (5–12 weeks of pregnancy). Ultrasound examination in all pregnant women was initially performed in a bidimensional fashion with a transvaginal 6.5-MHz probe and subsequently using a three-dimensional technique. Results: In the pregnant diabetic women the diameter of the yolk sac was significantly higher than that of controls in the first weeks of pregnancy, reaching a maximum diameter at 9 weeks, and decreasing thereafter, earlier than controls. The volume of the yolk sac increased in both groups from 5 weeks of pregnancy and reached maximum values at 10 weeks in both groups. The volumetric increase and decrease after reaching highest values were greater in IDDM patients. Conclusion: The clinical and diagnostic implications of the results of this study are still to be defined. Such a diagnostic technique may prove to be an additional element in monitoring diabetic women during early pregnancy.

Aims: Cellular turnover may be involved in remodeling of the cervix during parturition. Therefore, the number and localization of apoptotic and proliferating cells during cervical dilatation at term were determined. Methods: Biopsy specimens from the lower uterine segment of 36 women undergoing cesarean section with a cervical dilatation of <2 cm (n = 10), 2–<4 cm (n = 9), 4–6 cm (n = 8), and 6 cm (n = 9) were examined for nuclear fragmentation by the TUNEL assay, and for cell survival by the apoptosis-blocking bcl-2. Proliferation was marked by Ki-67, epithelial cells by cytokeratin and leukocytes by CD 45. For quantification of apoptotic and proliferating cells, eight random fields of each specimen stained for TUNEL or Ki-67 were blindly counted by two investigators. For statistical evaluation, 90% confidence intervals based on a Poisson distribution were used; groups with non-overlapping intervals were considered significantly different. Results: Apoptotic cells were found exclusively within the stromal compartment, while bcl-2 was expressed in epithelial cells and leukocytes. Proliferating cells were of stromal and epithelial origin. The number of apoptotic as well as proliferating cells ranged from 0 to 2 cells per high-power field (median number 0) in all groups. The confidence intervals were overlapping for all groups, showing no statistical difference between them. Conclusion: Apoptosis does not seem to play a decisive role in the process of cervical dilatation during parturition at term.

Objective: To determine whether an amnioreduction via bulging membranes (AVBM) and cerclage could be useful in 17 women with singleton gestations demonstrating hourglass membranes bulging out of the cervix or vaginal orifice. Methods: We used the following selection criteria for AVBM under ultrasonographic guidance using a peit needle because of undetectable cervical edges: (type 1) the bag of membranes protruded beyond the inlet of the vagina; (type 2) the bag of huge membranes completely occupied the vagina. Results: Eight patients (three cases of type 1 and five of type 2) were successful in AVBM and cerclage at 22.1±2.2 weeks gestation (range 19–24 weeks), and mean birth weight was 1,048.1±801.6 g (range 302– 2,688 g). Although the diameter of the forewater by transabdominal ultrasonography (cm) was higher than in the nine patients without AVBM (6.7±1.1 versus 4.1±0.7 cm, p=0.002), the prolongation of pregnancy (32.9±46.2 days; range 2–133 days) was the same as in patients without AVBM (36.9±39.3 day, p=1.000). Conclusion: It is important that every effort should be made to perform cervical cerclage at or before 26 weeks of gestation, even in women with type 1 or 2.

Aim: To investigate the influence of maternal and cord serum and amniotic fluid growth hormone (GH) and insulin and other neonatal and maternal factors on birthweight. Methods: A total of 160 pregnant women at 38–42 weeks' gestation were studied. All infants were categorized as small for gestational age (SGA) (n = 50), large for gestational age (LGA) (n = 50) or average for gestational age (AGA) (n = 60). GH and insulin levels were measured in maternal and cord serum and amniotic fluid at birth. Results: GH levels in maternal and cord serum and amniotic fluid showed no differences among the three weight groups (P > 0.05). The cord insulin level was significantly lower in SGA (P < 0.01). The insulin level in venous cord blood correlated with birth and placental weights and neonatal height, whereas maternal serum and amniotic fluid insulin levels, and maternal and cord serum and amniotic fluid GH levels did not show any correlation with birthweight. The cord GH level at birth was correlated with GH levels after 4 postnatal weeks in the SGA group (P < 0.01). In addition, birthweight showed a correlation with prepartum maternal weight, maternal weight gain, maternal height, neonatal length and placental weight in all three weight groups. Conclusions: Cord GH, maternal serum and amniotic fluid GH and insulin levels did not correlate with birthweight in all three weight groups. The lack of correlation for GH levels in maternal and cord serum and amniotic fluid suggests that these compartments may be noncommunicating separate units.

Objective: To determine the accuracy of birth weight in different birth weight (BW) groups using widely accepted formulas for fetal weight estimation (EFW). The secondary purpose was to estimate the role of examiners on the accuracy of EFW. Methods: The cross-sectional data were obtained from 5612 pregnant women. Fetal weight was estimated for each fetus using the formulas of Campbell and Wilkin, Shepard, 2 formulas of Hadlock and Merz. Inclusion criteria were: singleton pregnancy, complete ultrasound parameters, EFW obtained within the last week prior to delivery, the live born infant without congenital malformations or hydrops. Results: The highest intraclass correlation coefficient and the most stable results in all BW groups were generated with both Hadlock formulas. Both Hadlock and Campbell formulas had the lowest percent errors (PE) in BW groups between <1500 g and 3500 g. Shepard and Merz formulas had lower PEs in BW groups between 3501 g and >4000 g. However in BW groups under 3500 g they were imprecise. The PE of EFW varied from −4.0±8.5% to 1.3±8.5% between examiners. Conclusions: Both Hadlock formulas showed the most stable results in all of the weight groups. There is also a need for routine evaluation of the accuracy of EFW for every examiner, to make suggestions, what fetal measurements must be improved to improve EFW.

An atypical pattern of chronic lung disease (CLD) has been described in preterm infants and a potential association with intrauterine inflammation has been proposed. We aimed to describe patterns of CLD, to determine the incidence of atypical CLD, and to compare the distribution of various perinatal factors in infants with classic and atypical CLD. Information about demographics, respiratory status and various perinatal variables was collected for all neonatal admissions <1250 g. CLD was defined as oxygen dependency at 28 days of age. Ninety (51%) survivors at 28 days of age developed CLD; of these 37 (41%) were classified as atypical CLD. Factors significantly and independently associated with development of atypical CLD included being inborn, receiving natural surfactant, fewer days of mechanical ventilation within the first 28 days of life and higher birth-weight. Chorioamnionitis, postnatal infection and symptomatic PDA were not found to be significantly associated with atypical CLD. Atypical CLD is a common pattern of prolonged oxygen dependency in preterm survivors and is a feature of larger, more mature babies. Our findings do not support the hypothesis that exposure to intrauterine inflammation is an important aetiological factor in the development of atypical CLD.

We identified seventeen infants with Down syndrome without structural congenital heart disease who presented with persistent pulmonary hypertension in the newborn period. Respiratory distress with or without hypoxia was the presenting feature in these infants. Pulmonary hypertension resolved in the majority of the survivors. Two infants with refractory pulmonary hypertension benefited from patent ductus arteriosus ligation. Autopsies in two infants demonstrated structural lung immaturity. We suggest that infants with Down syndrome are at risk of developing persistent pulmonary hypertension even in the absence of structural heart disease and these infants should be followed up until resolution of the pulmonary hypertension.

Progress in perinatal and postoperative techniques has reduced the prognostic role of traditional risk factors in esophageal atresia (EA). This paper reports on 75 cases of esophageal anomalies observed between 1992 and 2002 and followed after surgery from a minimum of six months to a maximum of ten years (mean five years). The impact on survival of birth weight, week of delivery, associated anomalies and need of ventilatory support at birth are discussed. Twenty-four patients were born before 37 weeks of gestation, 18 weighed less than 2000 g.; major anomalies affected 11 neonates, 23 cases required mechanical ventilation at birth. Seventy-four patients were operated on with a 90.6% survival rate; no deaths were related to surgical treatment. Three cases required reoperation for postoperative complications. Birth weight and week of delivery did not seem to influence outcome; this is affected by severe associated cardiovascular anomalies and the need of ventilation at birth. Follow up at 24 months on 51 patients, revealed respiratory problems in 12 cases and severe gastro-esophageal reflux in 16. This affected quality of life of EA patients and required long term medical attention; improvement with growth was observed. No correlation between perinatal conditions and late sequelae could be demonstrated in our series.

Aims: Clinical follow-up of possible fetal complications associated with maternal parvovirus B19 infection is usually recommended during the 2–3 months after primary infection. Results: A case of late intrauterine fetal death associated with at least 5 months of maternal parvovirus B19 viremia and in the presence of B19 IgG and IgM is described. Conclusions: The time of clinical and laboratory followup after maternal parvovirus B19 infection may need to be revised if prolonged viremia is more common than previously described.

A case of postpartum acute myocardial infarction with intraventricular thrombus occurred in a woman with HELLP syndrome. Since coronary artery disease was ruled out angiographically, the assumed pathophysiological mechanism for myocardial malperfusion was intermittend coronary vasospasm and thrombosis. There were several thrombophilic risk factors detectable (heterozygous factor V Leiden, low levels of antithrombin III, protein S deficiency), whose possible impact in this rare but severe clinical condition is discussed.

Cervical pregnancy is a rare obstetrical complication. Conservative management with systemic methotrexate has been reported to be successful, obviating the need for surgical treatment which entails a risk for hysterectomy. We report the case of a nulliparous patient with a cervical pregnancy diagnosed at 9 weeks' gestation who after systemic methotrexate treatment necessitated conservative surgical management. This patient highlights the utility of identified risk factors for failure of methotrexate treatment.

We describe a case of cord blood harvest for autologous transfusion in a neonate weighing 3,992 g with a giant sacrococcygeal teratoma. The umbilical vein was pierced with an 18-gauge needle, and placental blood was withdrawn into two 50-ml syringes filled with 4 ml of citratephosphate-dextrose solution. Resection of the sacrococcygeal teratoma was performed on day one. During the operation the infant lost 46 ml of whole blood, more than 15% of the estimated total blood volume, and thus underwent autologous transfusion with 27.8 ml of packed red cells obtained from autologous cord blood. Consequently, she could avoid homologous blood transfusion during the hospital stay. This case highlights the safety of this procedure, with no evidence of consumption coagulopathy, hemolysis or bacterial infection.

Intussusception is an extremely rare disorder in preterm infants and it is often misdiagnosed as necrotizing enterocolitis. We report a case of intussusception in a 30-day-old preterm infant of 26 weeks of gestational age and a birthweight of 610 g who was diagnosed via abdominal ultra sonography. A systematic review of the literature was performed and reports on 23 previous cases were found. The presence of recognizable causes of intussusception in preterms, such as Meckel's diverticulum, bowel polypus, etc. was very infrequent. Comorbidity before and after intussusception is heterogeneous and related to prematurity. The intussusception is predominantly located in the small bowel (91,6%)–ileal or jejunal. The condition is misdiagnosed as NEC and managed conservatively until clinical deterioration occurs. A definitive diagnosis is thus established during abdominal surgery, which is usually delayed an average of 9.5 days from the onset of symptoms. Our case illustrates the capability of abdominal ultrasonography to establish early diagnosis of intussusception in the premature newborn.