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The purpose of this study is to assess whether serum beta-human chorionic gonadotropin (beta-hCG) levels on day 4 following methotrexate (MTX) treatment in patients with ectopic pregnancy predict successful single-dose therapy or the need for subsequent surgical intervention. Retrospective analysis of patients with ectopic pregnancies treated with MTX (50 mg/m (2)) was conducted. Inclusion criteria for MTX management were serum beta-hCG < 15,000 mU/mL, absent fetal cardiac activity, ultrasonographic gestational sac < 3.5 cm, normal liver function tests, hemodynamically stable patient with no evidence of hemoperitoneum, and informed consent. Day 1, 4, and 7 serum beta-hCG levels were obtained. Outcome parameters included successful single-dose MTX management, the requirement for multiple treatments, and whether subsequent surgery was required. Receiver operator characteristic (ROC) curves were used. P < 0.05 was considered significant throughout. Eighty-three patients were studied. Of these, 60 patients were treated successfully with single doses, 16 patients required two doses, and two patients required three doses of MTX, and five underwent surgical management. Mean day 1 serum beta-hCG levels of patients successfully treated with single-dose MTX was 3938.5 (+/- 589.2 [standard deviation]) versus 1767.65 (+/- 1237.8) mU/mL in patients requiring multiple doses of MTX therapy, ( P < 0.0001). ROC curves for serum beta-hCG levels on days 1, 4, and 7 were 0.449, 0.592, and 0.754, respectively, indicating that only day 7 serum beta-hCG levels were associated with successful single-dose MTX therapy. Serum beta-hCG levels on day 4 of MTX in patients with ectopic pregnancy do not predict successful single-dose therapy or the need for surgery.

Cervical pregnancy is an uncommon ectopic pregnancy that accounts for approximately

We present an unusual case of a primigravida with a viable cervical pregnancy diagnosed by transvaginal ultrasound and magnetic resonance imaging. Staggered conservative therapeutic measures included systemic high-dose Methotrexate with Folinic acid rescue followed by bilateral embolization of the uterine arteries in response to active cervical bleeding despite declining serum beta-human chorionic gonadotropin levels. Continued active cervical bleeding responded to local tamponade with an inflated Foley catheter balloon positioned within the cervical canal. Conservative treatment was successful, with complete resolution of the cervical pregnancy, resumption of normal menstrual cycles, and a normal transvaginal ultrasonographic appearance of the cervical canal, documented 8 weeks after the initial diagnosis. This case and review of the literature support that various staggered conservative hemostatic measures may be used at various points in which bleeding may occur in the conservative management algorithm of cervical pregnancy.

The differential diagnosis of reflective intrauterine membranes during pregnancy includes amniotic bands of fetal origin or membranes of combined maternal-fetal origin. While the former have been associated with fetal transverse reduction defects or the lethal amniotic band syndrome, the latter are usually benign and consist of a preexisting uterine septation or synechia around which the fetal membranes fold or become enveloped. We present an unusual case in which a patient was noted at 19 weeks' gestation to have an intrauterine membrane of undetermined origin, appearing to contain a pulsating vessel. Color Doppler imaging and Doppler flow velocimetry clearly depicted a pulse synchronous with the maternal heart rate, defining the membrane as amniotic membranes surrounding a preexisting uterine synechia and not a true amniotic band. The pregnancy was otherwise uneventful and the patient delivered a healthy neonate at elective repeat cesarean at which time the presence of the uterine synechia was confirmed.

Traditionally, oligohydramnios has been implemented as a sign of potential fetal compromise and associated with an increased incidence of adverse perinatal morbidity and mortality. Decreased amniotic fluid volume is especially of concern when it occurs in conjunction with structural fetal anomalies, fetal growth restriction, postdates pregnancies, and maternal disease. Consequently, following ultrasonographic diagnosis of oligohydramnios at term, delivery is routinely advocated even in otherwise uncomplicated pregnancies with an appropriate-for-gestational-age fetus, irrespective of the presence of reassuring fetal evaluation and the absence of maternal disease. Numerous factors complicate the ultrasonographic diagnosis of oligohydramnios. These include a lack of complete detailed understanding of the physiology of the dynamics of oligohydramnios, the transient condition at times of decreased amniotic fluid volume, generally poor performance of ultrasonography in detecting oligohydramnios, an array of different ultrasound diagnostic criteria, and varying ultrasonographic thresholds. In light of the latter and the lack of prospective randomized data, is unclear that the practice of effecting delivery for isolated oligohydramnios at term is justified. This article presents physiologic dynamics of amniotic fluid, factors that may affect amniotic fluid volume, possible pitfalls in the ultrasonographic assessment of amniotic fluid volume, and the clinical significance of oligohydramnios. In addition, the literature regarding perinatal outcome associated with oligohydramnios and current available data supporting expectant noninterventional management of cases complicated by isolated oligohydramnios at term are discussed.

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.

Hyperemesis gravidarum or pernicious vomiting of pregnancy affects between 0.3% and 2% of all pregnant patients. The objective of this paper is to review current literature pertaining to epidemiology, etiology, symptomatology, complications, treatment, and perinatal outcome of patients with hyperemesis gravidarum. We performed a MEDLINE search of the English literature from 1966 through January 2000 utilizing the keywords: hyperemesis gravidarum, nausea and vomiting, and pregnancy. Current data pertaining to epidemiology, etiology, clinical manifestations, differential diagnosis, complications, various treatment modalities, subsequent perinatal outcome and recent developments are presented. Review of the literature supports that hyperemesis gravidarum is a multifactorial disease in which pregnancy-induced hormonal changes associated with concurrent gastrointestinal dysmotility and possible Helicobacter pylori infection function as contributing factors. Therapeutic key elements are mainly supportive in conjunction with antiemetic medication. It appears perinatal outcome is unaffected.

We present an unusual case in which a patient with asthma presented with acute respiratory distress of acute onset, secondary to marked atelectasis of the right middle and lower lobes, which resolved within 24 hr following administration of increased doses of intravenous steroids, inhalation therapy (beta-agonists and steroids), and pulmonary physiotherapy. This transient occurrence responding to basic therapeutic measures was considered consistent with the release of a mucous plug which had caused the above obstruction and associated symptomatology and radiographic findings. This case illustrates and supports the practice of chest imaging in patients with atypical presentations of asthma and stresses the importance of pulmonary physiotherapy and bronchodilatory therapy as primary therapeutic agents in cases of mucous plug-associated atelectasis.

Objective: Ultrasound (US) is currently available on most if not all Labor and Delivery (L+D) services. Our objective was to survey utilization of real-time US on L+D in an active academic teaching hospital. Study Design: Between April 1, and July 31, 1998, all US examinations performed for clinical purposes on patients presenting to L+D, were documented. Data collected included: gestational age, whether or not the patient was in labor, number of fetuses, and indication for US. All US examinations were performed by OB/GYN housestaff at the PGY 2-3 level, and fellows in Maternal-Fetal Medicine. Statistical analysis included Student's t-test and X 2 when appropriate, with p < 0.05 considered significant throughout. Results: During the 4-month study period, 1316 patients delivered and 1363 were discharged from L+D, not in labor. Of 630 US examinations 31.64% (192 of 630) and 67.69% (418 of 630) were performed in laboring versus nonlaboring patients, respectively. Of all patients delivered during the study period, 14.5% (192 of 1316) underwent intrapartum US, and of all nonlaboring patients, 30.66% (418 of 1363) underwent US on L+D. The mean gestational age at the time of assessment was 37. 32 ± 4.23 weeks' versus 35.74 ± 5.76 weeks' gestation, in laboring versus nonlaboring patients respectively, p < 0.05. Main indications for US in patients in labor were; fetal presentation in patients with spontaneous rupture of membranes (SROM) 34.4% (n = 66), confirmation of vertex presentation 20.3% (n = 39), preterm labor 12% (n = 23), multiple gestation 7.3% (n = 14), and malpresentation 7.3% (n = 14). Main indications for patients not in labor were; amniotic fluid index 15.8% (n = 66), SROM 15.6% (n = 65), postdates 9.8% (n = 41) placental location 9.6% (n = 40), and decreased fetal movement 9.3% (n = 39). Ultrasound-guided interventions included: all deliveries of multiple gestations (n = 9), version in nonlaboring patients (n = 10), and postpartum curettage for retained placental tissue in conjuction with severe early postpartum hemorrhage (n = 2). The incidences of each separate indication for US were significantly different between laboring versus nonlaboring patients, p < 0.05, respectively. Conclusion: US examination is performed in 15% of patients in labor and 31% of patients not in labor assessed on L+D, constituting a widely applied diagnostic tool in this environment.

Glanzmann's thrombasthenia is a rare autosomal recessive bleeding disorder resulting from a deficiency of glycoprotein IIb-IIIa complex in platelets. The deficient complex normally mediates platelet aggregation by binding adhesive proteins, which form bridges between activated cells. Despite normal platelet counts, morphology, prothrombin, and activated thromboplastin times, Glanzmann's thrombasthenia is characterized by a prolonged bleeding time and a severe hemorrhagic mucocutaneous diasthesis. Pregnancy and delivery are rare in these patients and have been associated with a high risk of severe hemorrhage. We present an unusual case in which a primi-gravida patient with Glanzmann's thrombasthenia underwent an uneventful pregnancy and spontaneous vaginal delivery, following intrapartum intravenous administration of single-donor platelets. Subsequent late postpartum hemorrhage required intravenous transfusion of an additional unit of single-donor platelets. In addition, we review the literature pertaining to pregnancy and Glanzmann's thrombasthenia with an emphasis on intrapartum prophylactic management.

We present an unusual case, in which a woman presenting with markedly decreased fetal movements at 29 weeks gestation following a recent increase in fundal height was noted sonographically to have fetal hydrops consisting of scalp edema, marked hepatomegaly, ascites, and polyhydramnios. No lethal structural congenital anomaly was noted. Admission laboratory examinations revealed a negative antibody screen and a negative RPR. Emergent cesarean section was performed due to prolonged fetal bradycardia during biophysical profile testing. The acidotic hydropic neonate weighing 1825 g was resuscitated yet succumbed at 3 hr of life following intravenous administration of antibiotics. Neonatal blood was RPR positive at 1:16. Postmortem pathology examination demonstrated severe multiorgan system failure secondary to overwhelming congenital syphilis. Extensive extramedullary hematopoiesis was noted and histopathology with Dieterle stains revealed numerous hepatic spirochetes. Postpartum reexamination of the maternal blood with serial dilutions revealed a positive RPR at 1:1024. This case emphasizes that initial negative screening for syphilis may be seen despite overwhelming infection, a condition that has been termed the "prozone effect."

Objective: To determine whether the forewaters should be considered in the assessment of amniotic fluid (AF) volume in patients beyond 37 weeks' gestation. Methods: Sixty patients were prospectively studied and designated as having oligohydramnios or normal AF volume based upon on the standard four-quadrant AF index (AFI) of ≤5 cm or >5 cm, respectively. The distance between the internal os and the fetal head was measured transvaginally. This measurement was first added to the standard AFI and subsequently interchanged with the lowest of the two lower abdominal quadrant measurements. Statistical analysis included Student's t-test with p < 0.05 considered significant. Results: Thirty patients were classified as oligohydramnios and 30 normal AF volume. The two subgroups did not differ as to maternal age, parity, gestational age at sonographic examination, incidence of meconium-stained amniotic fluid or 5-min Apgar scores

We present an unusual case in which sonographic assessment at 33 weeks' gestation, 5 weeks following a normal fetal anatomical survey and biometry, demonstrated a large, irregular-shaped, echogenic, suprasellar midline intracranial mass occupying the anterior and middle fossas. Associated severe obstructive hydrocephalus with "dangling" choroid plexus bilaterally was noted with a markedly thin cortical mantle and increased cranial biometry. Elective cesarean delivery was performed due to the associated craniomegaly at 37 weeks' gestation. Although breathing spontaneously at delivery, the infant subsequently required mechanical ventilation and developed neonatal seizures. A ventriculoperitoneal shunt was placed on Day 3 of life. Transcranial needle biopsy demonstrated malignant astrocytoma (glioblastoma multiforme). This case suggests the rapid development of an intracranial malignant astrocytoma over a relatively short period of time. The significant ultrasonographic finding of an intracranial, destructive fetal deformation, following a normal examination 5 weeks previously, demonstrates the limitations of screening ultrasonography in predicting perinatal outcome.

Our objective was to determine if placental histologic acute inflammation is related to maternal and fetal serum cytokine levels in preterm labor, using a data set previously constructed blinded to histopathologic information. To this goal in 1992, 32 consecutive patients at 20-36 weeks with progressive labor and tocolytic failure were recruited. Maternal serum sampled during the active phase of labor, and fetal (umbilical vein) serum were assayed by ELISA for levels of soluble interleukin-1 beta (IL-1 beta), soluble interleukin-2 receptor (IL-2 R), and interleukin 6 (IL-6) (T-Cell Diagnostics). Acute placental inflammation was scored by two groups blinded to clinical data, and the average scores analyzed for relationships to serum cytokine levels. Weighted kappa values, reflecting interobserver agreement in scoring of acute inflammation, were: amnion 0.84; choriodecidua 0.84; umbilical cord 0.85; and chorionic plate 0.73. Fetal levels of IL-1 beta and IL-2 R were higher with grade 3-4 acute amnionitis than with grades 0-2 (p = 0.022 and p = 0.023). Fetal levels of all three cytokines were higher in grade 3-4 umbilical vasculitis (IL-1 beta p = 0.008, IL-2 R p = 0.01, and IL-6 p = 0.03). In contrast, maternal serum cytokine levels were not associated with presence or severity of histologic evidence of acute placental inflammation. Histologic acute inflammation was not related to duration of labor, interval from membrane rupture to delivery, and presence or duration of antibiotic therapy. We conclude that fetal serum, but not maternal serum cytokine levels, are correlated with histologic evidence of acute placental inflammation, and may reflect a predominant placental origin of the cytokines.

The objective of this study was to assess the relationship between amniotic fluid volume (AFV) and fetal movements at32 weeks gestation as assessed by routine biophysical profile (BPP). From a database of 465 consecutive nonhypertensive, nondiabetic patients delivering at32 weeks gestation, patients with singleton, nonanomalous fetuses with AFV and fetal movements determined as part of a BPP assessment within 24 hours of delivery were studied. Amniotic fluid volume was scored 0 to 2, according to the following criteria: largest pocket in vertical diameter1 cm = 0;2 but1 cm = 1;or = 2 cm = 2. Fetal movements (FM) were scored over 30 minutes: 0 if absent, 1 if 1 to 2 movements, 2 ifor = 3 gross (limb/trunk) movements. Variables assessed included fetal presentation, gestational age (GA), premature rupture of membranes (PROM) as a principal indication for delivery, clinical chorioamnionitis (diagnosed by previously published criteria), histologic parameters of infection (in amnion and umbilical cord assessed by a single pathologist blinded to clinical data), and neonatal outcome. Statistical analyses included contingency tables and analysis of variance with p0.05 considered significant. Three hundred and fifty-two patients met the inclusion criteria. One hundred and sixty-seven patients (47%) had PROM as a primary indication for delivery. Infrequently, decreased fetal well-being manifested by a BPP7 of 10 points was an indication for delivery despite prematurity (n = 7). Of the 352 patients, 80 (23%) had AFV = 0, 60 (17%) had AFV = 1, and 212 (60%) had AFV = 2; and 12 (3%) had FM = 0, 30 (9%) FM = 1, and 310 (88%) FM = 2. There was a significant correlation between decreased AFV and decreased fetal movements (p0.0001). Fetal presentation and GA were not significantly different between patients based on score of fetal movements. The incidence of clinical chorioamnionitis was significantly greater in patients with FM = 0 (p0.005). We conclude that decreased AFV is associated with decreased fetal movements irrespective of fetal presentation or gestational age. Neonatal outcome (umbilical vasculitis, sepsis, intraventricular hemorrhage) is affected only in unusual cases in which otherwise uncompromised (nonhypoxic, nonacidotic) fetuses have low scores on both these antepartum ultrasonographic parameters.

We present an unusual complication of midtrimester genetic amniocentesis of a monochorionic twin gestation in which prolonged fetal bradycardia of 60 to 80 beats per minute sustained over two hours was associated with multiple subsequent fetal anomalies. These included: microcephaly, bilateral closed-lip schizencephaly, duodenal atresia, and complete paresis of the left upper extremity. Etiology of the fetal bradycardia was unclear. Fetal hemorrhage was not visualized despite targeted, continued real-time ultrasonography and was therefore considered an unlikely etiology. Although the bradycardia and associated hypoperfusion could alone explain the fetal outcome, destabilization of hemodynamics of a communicating vessel, resulting in a possible (although unproven) acute twin-twin transfusion induced at the time of amniocentesis due to decreased intra-amniotic pressure in association with a velamentous umbilical cord insertion could have led to this unusual occurrence.

Prenatal sonographic diagnosis of an unusual case of a large left congenital diaphragmatic hernia is presented. The fetal stomach was located within the right thorax, posterior to the dextropositioned heart. Color and pulsed Doppler ultrasonography documented intrathoracic umbilical vein and ductus venosus vessels and respective waveforms, confirming extensive herniation of the left hepatic lobe.

We report the prenatal ultrasonographic diagnosis of a fetus with mandibulofacial dysostosis (Treacher Collins syndrome). Sonographic findings included : polyhydramnios, microcephaly, abnormal fetal facial features (slanting forehead, microphthalmos, micrognathia), and abnormal fetal swallowing. A review of the current literature pertaining to prenatal diagnosis of this condition is presented.

It is uncertain whether idiopathic midtrimester polyhydramnios is associated with adverse perinatal outcome. Fifty patients with midtrimester polyhydramnios without apparent etiology were compared to 85 control patients. Demographic, obstetric, and neonatal data were recorded and compared using chi-square, Fisher's exact, and Student t tests. Comparisons were also made within the study group between those patients with resolution of the polyhydramnios and those with persistence. Demographic and obstetric data were similar in both groups. Of study patients, 94% had mild polyhydramnios, which resolved in 75.6% of those having follow-up scans. There were no differences in neonatal outcome between study and control groups. Fetal aneuploidy was increased in the persistent polyhydramnios group (2 of 10, 20%) compared to the group with spontaneous resolution (none of 33, 0%), P = 0.049. Mild idiopathic midtrimester polyhydramnios resolves frequently and, if so, is not associated with adverse perinatal outcome. However, persistence of polyhydramnios is associated with an increased risk of fetal aneuploidy, and fetal karyotyping should be considered.

Unusual sonographic visualization of the interlobar fissure of the herniated fetal liver in a case of right congenital diaphragmatic hernia was misinterpreted as the right diaphragm leading to misdiagnosis of this fetal anomaly.

A prospective study of 98 pairs of nonstress tests (NSTs) was obtained simultaneously from members of 30 twin gestations. Fifty-five percent of the total fetal heart rate (FHR) accelerations of both twins were associated with each other and occurred within 15 seconds of each other. There were 8.46% synchronous FHR accelerations of both twins, possibly reflecting evoked fetal movements. Statistical analysis failed to reveal evidence of a dominant twin in utero, with one twin initiating the majority of coinciding fetal movements with statistical significance in only three gestations. Examination of combinations of the 30 separate individual significance tests using techniques of meta-analysis demonstrated a p value of 0.81, indicating lack of dominance in any of the 30 pairs of twins. The probability plot, consistent with the large p value for the combination test statistic, suggested that fetal movements in two gestations are related, strengthening the hypothesis of in utero tactile communication between twins. We conclude that the existence of a "dominant twin" in utero cannot be detected by electronic FHR monitoring methods.

We present a case that describes a partial fetal response to external vibratory acoustic stimulation in that, although no fetal movements were elicited, a blunted, brief positive cardioacceleratory response was noted. This fetus exhibited features of the Pena-Shokeir syndrome, characterized by skeletal neurogenic atrophy, yet with a normal auditory system at autopsy. This observation may suggest that the prolonged increase in the basal fetal heart noted after fetal vibratory acoustic stimulation is sustained by active fetal movements, absent in this fetus due to joint contractures.

The Roberts-SC phocomelia syndrome (pseudothalidomide syndrome) is a rare, usually lethal condition involving short limbs and occasional hydrocephalus. Presented is a case in which prenatal sonographic findings were highly suggestive of this syndrome, although not definite. In this fetus, findings of hydrocephalus, short limbs, and probable pulmonary hypoplasia changed the intrapartum management. The findings, correlated with the postmortem radiography, led to diagnosis of probable Roberts-SC syndrome.

We present an unusual case in which a 36-year-old patient was referred for consultation due to increasing upper left abdominal pain at 35 weeks' gestation. Transabdominal ultrasonography disclosed an appropriate-for-gestational-age singleton, vertex-presenting fetus with normal anatomy. An unclear, complex, semisolid, semicystic mass was noted in the upper right abdomen. Due to the close proximity of the adnexal mass to the patient's abdominal wall, a high-frequency transvaginal transducer was applied transabdominally. Unlike the unclear images generated at conventional transabdominal ultrasonography, this application depicted a discrete mass with multiple characteristics consisting of calcifications, hair and fatty tissue, considered diagnostic of a mature cystic ovarian teratoma. The patient delivered spontaneously at 39 weeks' gestation. At 6 weeks' postpartum an elective laparotomy left ovarian cystectomy was performed and a mature cystic teratoma confirmed by pathology examination.

First-trimester sonographic findings associated with omphalocele-exstrophy-imperforate anus-spinal defects (OEIS) complex and review of the literature regarding this rare congenital anomaly are presented.

Preeclampsia is uncommon prior to 24 weeks gestation and has been associated with partial and complete hydatidiform moles. We present an unusual case in which a patient was diagnosed with preeclampsia at 17 weeks gestation. Ultrasound findings were consistent with a partial hydatidiform mole. Within 24 hours of the onset of symptoms, the patient developed severe hemolysis, elevated liver enzymes, and low platelet count syndrome, with a platelet count of 20 x 10 (9) cells/L. Termination of pregnancy was performed with rapid resolution of signs, symptoms, and laboratory abnormalities. Triploid 69,XXY was confirmed at karyotype analysis. This case demonstrates the acuteness in which life-threatening maternal conditions can arise with this uncommon complication of pregnancy, and the importance of correct identification of the characteristic ultrasonographic findings associated with a partial hydatidiform mole.

We present an unusual case in which a 23-year-old nulliparous patient was noted to have bilateral multicystic adnexal masses at 21 weeks gestation. Subsequent severe nausea, vomiting, and hyperglycemia with a serum glucose level of 450 mg/dL led to the diagnosis of gestational diabetes. Gradual development of marked maternal virilization ensued and was associated with a serum testosterone level of 4030 ng/mL (free testosterone level of 224 pg/mL), with normal serum dehydroepiandrostendione, estriol, and cortisol levels, leading to the diagnosis of hyperreactio luteinalis. Following vaginal delivery at 38 weeks gestation, gradual and complete spontaneous resolution of signs, symptoms, adnexal masses, diabetes, and testosterone levels were documented.

We present prenatal sonographic diagnosis of unilateral dacryocystocele at 32 weeks' gestation and review the literature pertaining to diagnosis and management of this congenital abnormality.

Type 1 cystic sacrococcygeal teratomas, usually associated with good outcome following neonatal resection, must be differentiated at the time of prenatal diagnosis from sonographically similar meningomyeloceles, which carry a grave prognosis. We present an unusual case in which color Doppler imaging assisted correct midtrimester prenatal diagnosis of a large type 1 cystic sacrococcygeal teratoma closely simulating a meningomyelocele.

An increased incidence of thrombotic thrombocytopenic purpura has been reported among human immunodeficiency virus-infected patients or those with acquired immunodeficiency syndrome (AIDS). Despite this association, hitherto only a single case of thrombotic thrombocytopenic purpura has been reported in an HIV-infected patient during pregnancy. We describe a young multiparous patient with long-standing AIDS who presented with lower abdominal pain. Following findings of thrombocytopenia, microangiopathic hemolytic anemia, renal failure, low-grade fever, and mental status changes, thrombotic thrombocytopenic purpura was diagnosed after initially considering the diagnosis of severe preeclampsia, and the patient was delivered by cesarean section. The patient required multiple plasma exchanges during a protracted postpartum course, and was discharged in good health. This first report of thrombotic thrombocytopenic purpura and AIDS in pregnancy demonstrates that when encountering preeclampsia in patients with AIDS, thrombotic microangiopathy should be strongly considered. In addition, these patients may exhibit an attenuated response to plasma exchange therapy and despite previous reports in nonobstetric patients, a favorable outcome is attainable in these critically ill patients.

Uterine contraction-associated accelerations of the maternal heart rate are considered to reflect both a transient contraction-related increase in cardiac output and endogenous catecholamine secretion. Uterine contraction-associated decelerations of the maternal heart rate are rare and remain unexplained. A young multiparous patient with systemic lupus erythematosus (postrenal transplant for lupus nephropathy-related renal failure) presented in early labor at 39 weeks gestation, prior to elective repeat cesarean section. Intrapartum continuous maternal heart rate monitoring demonstrated repetitive uterine contraction associated decelerations of the maternal heart rate of 60 beats per minute, each lasting 2 minutes, simulating nonreassuring fetal status. Simultaneously depicted fetal heart rate was reassuring. This case demonstrates an unusual marked early intrapartum affect of uterine contractions upon the maternal heart rate. In addition, this case illustrates the potentially dangerous similarity of an intrapartum maternal heart rate to an abnormal fetal heart rate pattern, and emphasizes the importance of correct identification of the maternal and fetal heart rates, respectively.

A non-laboring patient with a breech-presenting fetus and oligohydramnios at 41 weeks' gestation underwent elective cesarean delivery. The infant was delivered atraumatically through a wide transverse incision of the lower uterine segment. Severe leftsided torticollis was noted immediately at delivery. The torticollis subsequently responded to physiotherapy with minimal residual facial asymmetry. This case and the literature suggest that torticollis itself may predispose to breech presentation. Alternatively, in the case presented, oligohydramnios with subsequent restricted posture may have contributed to the underlying pathophysiology of this phenomena, which previously has been noted as associated with and as a possible sequela of traumatic vaginal breech delivery.

The cavum septum pellucidum is a fluid-filled cavity located between the membranes of the septi pellucidi, which should always be visualized sonographically in normal fetuses between 18 and 37 weeks gestation and in approximately 50% of term infants. The cavum vergae, a cavity within the septum pellucidum, is located posterior to an arbitrary vertical plane formed by the columns of the fornix. We present a case in which markedly dilated cavum septum pellucidum et vergae noted at 29 weeks gestation was associated with midgut malrotation and volvulus, and review the literature pertaining to this unusual prenatal ultrasonographic diagnosis.

Maternal intravenous magnesium sulfate (MgSO4) therapy has been associated with decreased fetal heart rate (FHR) variability and reactivity, resulting in an increased incidence of nonreactive nonstress tests, frequently requiring further assessment of fetal well-being. This study was designed to assess fetal response to vibroacoustic stimulation in association with maternal intravenous MgSO4 therapy. Five gravidas with singleton gestations with normal fetal anatomy, intact membranes, and normal amniotic fluid volume at 31 weeks or more presenting with preterm labor were included. Vibroacoustic stimulation was performed prior to and during subsequent intravenous MgSO4 therapy so that each fetus served as its own control. Ultrasound was applied during vibroacoustic stimulation to assess fetal movement response. Response to vibroacoustic stimulation was considered normal if a FHR acceleration of at least 15 beats/min for at least 15 seconds occurred within 15 seconds after the stimulation with prolonged fetal movements. Maternal serum magnesium levels were obtained prior to each stimulation. All fetal responses prior to treatment were normal. All subsequent fetal responses in association with intravenous MgSO4 were abnormal, consisting of blunted FHR accelerations of 10 to 15 beats/min and ranging between 10 and 15 seconds in duration associated with brief limited fetal movements. Mean maternal serum magnesium levels (+/- standard error) during vibroacoustic stimulation, prior to and following intravenous MgSO4, were 1.4 +/- 0.1 and 5.2 +/- 0.4 mEq/L, respectively (P = 0.008). All 5-minute Apgar scores were 8 or higher. This occurrence may reflect an effect of magnesium on the fetus as either a central nervous system depressant or alternatively as a peripheral neuromuscular relaxant.(ABSTRACT TRUNCATED AT 250 WORDS)

We present transvaginal ultrasonographic findings of a fetus with Dandy-Walker malformation and associated massive obstructive hydrocephalus at 13 weeks' gestation. First-trimester ultrasonographic diagnosis of Dandy-Walker malformation is uncommon with only two such occurrences having been reported previously. These cases and recent reports of single gene transmission of this condition in some families emphasize the importance of first-trimester transvaginal ultrasound assessment especially in women with previously affected fetuses.

A 38-year-old para 2 presented with the gradual onset of nausea vomiting and increasing left lower quadrant pain, at 33 weeks' gestation. She was known to have uterine leiomyomas, with ultrasonography depicting an 8-cm intramural fundal leiomyoma. In addition a left lateral nondiscrete 10 x 8-cm mass was depicted at the point of maximum tenderness. Magnetic resonance imaging (MRI) demonstrated diverticulosis of the descending and sigmoid colon. The patient remained afebrile and received repeated doses of intramuscular analgesics and was cleared by the surgical consultant, only to be readmitted with similar symptomatology 24 hours later. Subsequently, following repeat discharge she delivered at 34 weeks' gestation, and developed a small bowel obstruction during the immediate postpartum course. With the continued finding of a left lower abdominal mass and computed tomography findings suggestive of perforated sigmoid diverticulitis and resulting small bowel obstruction, laparotomy was performed. Multiple adhesions and phlegmon sequelae of chronic perforation of the sigmoid were confirmed, and a diverting descending colostomy and Hartman's procedure were performed. We present unusual MRI findings of diverticulitis in the third-trimester and review the literature pertaining to this unusual complication of pregnancy.

Recurrent bilateral renal agenesis in siblings is very rare. Presented is a case diagnosed with sonographically aided amnioinfusion at 18 weeks in a woman with an infant affected with the same condition in a previous pregnancy.

The objective of this review is to assess the current literature pertaining to prenatal ultrasonographic diagnosis of various conditions that predispose the fetus to potential umbilical cord compression. We performed a MEDLINE search utilizing the terms:umbilical cord compression, nuchal cord, cord entanglement, and true knot. Additional sources were obtained through cross-referencing. Prenatal ultrasound assists in the diagnosis of nuchal cord(s), true knot of the umbilical cord, cord entanglement in monoamniotic twin gestations, and other unusual etiologies that may lead to umbilical cord compression. Supplementary ultrasonographic measures including color Doppler imaging, Doppler flow velocimetry, and possibly three-dimensional ultrasound may further prenatal diagnosis of these conditions. Doppler flow velocimetry may also assist in detecting impaired or deteriorating umbilical artery flow reflecting increasing cord compression prior to the onset of adverse and potentially nonreversible effects upon the fetus. Close fetal surveillance in cases further complicated by decreased fetal movements, decreased amniotic fluid volume, postdates, fetal growth restriction, and impaired umbilical artery Doppler flow velocimetry may assist in the management of such gestations. Although definitive prospective studies investigating neonatal outcome following prenatal ultrasonographic depiction of potential umbilical cord compression are not currently available, review of the literature suggests that increased fetal surveillance may be indicated in certain clinical conditions.

Fetal ultrasound examination at 29 weeks' gestation revealed a severely symmetrically growth-retarded fetus with microcephaly, hypertelorism, and hypoplastic genitalia with a two-vessel umbilical cord. G-banding analysis on amniotic cell cultures revealed a 46, XY,r(4)(p15-q35) karyotype in each of the colonies analyzed. This prenatal diagnosis, to our knowledge the first reported, assisted clinical management of this pregnancy.

The objective was to review current literature pertaining to first-trimester nuchal translucency screening for fetal aneuploidy. To this goal, all manuscripts published in the English language regarding this topic obtained from a MEDLINE search for 1966 through November 1998 were selected and reviewed. Additional sources were identified through cross-referencing. Current widespread application of first-trimester ultrasonography has enabled accumulation of an increasing body of knowledge pertaining to early screening for fetal aneuploidy. Following initial reports, recent studies of large populations of patients (> 500 participants) at either high- or low-risk for fetal chromosomal abnormalities, demonstrate that nuchal thickness of > 3 mm between 10 and 14 weeks' gestation by either transabdominal or transvaginal ultrasonography may serve as screening tool for fetal aneuploidy. Sensitivity and specificity rates improve when first-trimester maternal serum free beta-human chorionic gonadotropin (hCG) and pregnancy associated plasma protein A (PAPP-A) levels are added to this ultrasonographic tool. Current data regarding nuchal translucency including: nomograms, repeatability, optimal timing of measurement, accuracy and effect of confounding factors upon this ultrasonographic measurement, pathophysiology, increased associated incidence of fetal cardiac anomalies, and arrhythmias as well as other structural anomalies, Doppler velocimetry, spontaneous subsequent miscarriage, implications of nuchal translucency in twin gestations, and effect upon performance of subsequent midtrimester maternal serum screening are presented.

A recent, prospective randomized trial has suggested that long-term use of prophylactic beta-adrenergic blocking agents may slow the rate of aortic dilation in those patients with Marfan's syndrome exhibiting evidence of existing dilation. Accordingly, administration of such medication from the midtrimester onward has been advocated in these patients. Acute oral administration of propranolol (80 mg) has been shown to depress fetal heart rate response to vibroacoustic stimulation. We present a case in which chronic administration of propranolol 150 mg/day to a patient with Marfan's syndrome with existing aortic root dilation was associated with repeated abnormal intrapartum fetal heart rate responses to vibroacoustic stimulation. Subsequent delivery of a nonhypoxic, nonacidotic infant suggests that maternal administration of beta-blockers should be considered in the interpretation of results of fetal vibroacoustic stimulation. This case also supports that in similar clinical presentations, ultrasonographic confirmation of the fetal startle response, or alternatively observation of the resulting fetal recoil may be utilized rather than the fetal heart rate, which may be modulated by maternal medications.

Our objective was to review current literature pertaining to antepartum fetal intracranial hemorrhage. To this goal we selected all manuscripts published in the English language regarding this topic obtained from a MEDLINE search for 1966 through January 1998. Additional sources were identified through cross-referencing. Antenatal fetal intracranial hemorrhage may occur spontaneously, or occur in association with various maternal or fetal conditions. Predisposing maternal conditions at risk for this occurrence include alloimmune and idiopathic thrombocytopenia, von Willebrand's disease, specific medications (warfarin) or illicit drug (cocaine) abuse, seizures, severe abdominal trauma inflicting subsequent fetal injury, amniocentesis, cholestasis of pregnancy and febrile disease. Predisposing fetal conditions include congenital factor-X and factor-V deficiencies, hemorrhage into various congenital tumors, twin-twin transfusion, demise of a co-twin, or fetomaternal hemorrhage. Currently, antepartum fetal intracranial hemorrhage may be diagnosed by imaging techniques including ultrasonography and less frequently, magnetic resonance imaging. Early real-time sonographic signs of intracranial hemorrhage consist of irregular echogenic patterns representing the associated hematoma that may clearly distort normal intracranial structures. Recent reports have suggested Doppler flow velocimetry and color Doppler imaging as additional tools in detecting fetal intracranial hemorrhage. Various types of antenatal fetal intracranial hemorrhages that have been visualized sonographically include intraventricular, periventricular, subependymal, parenchymal, subdural, and intracerebellar events. Active hemorrhages may be associated with fetal distress manifested by fetal heart rate changes. Infrequently, antenatal ultrasonographic depiction of intracranial hemorrhage may precede devastating sequelae such as hydrocephalus, hydranencephaly, porencephaly, or microcephaly. Due to the significant associated neonatal neurological impairment and potential medicolegal implications of antepartum fetal intracranial hemorrhage, it follows that obstetricians and sonographers should be familiar with predisposing factors and typical diagnostic imaging findings of these events.

Objective: to assess perinatal outcome in post-term pregnancies in which fetal heart rate (FHR) monitoring revealed either uncomplicated baseline fetal tachycardia (≥ 160 bpm) or fetal bradycardia (≤ 120 bpm). Study Design: We performed a case-control study of patients who underwent fetal assessment between July 1989 and June 1995, as part of post-term evaluation. Inclusion criteria consisted of nonlaboring afebrile patients with singleton post-term pregnancies ≥ 41 weeks of gestation by strict dating criteria (last menstrual period consistent with ultrasound biometric parameters obtained prior to 20 weeks' gestation), normal fetal anatomy, intact membranes, and reactive nonstress test with no evidence of chorioamnionitis. Patients with fetal tachy or brady arrhythmias, FHR decelerations, or loss of short-term beat-to-beat variability were excluded. Baseline FHR was recorded retrospectively by an observer blinded to maternal and neonatal clinical outcome. For each case of uncomplicated baseline fetal tachycardia (≥ 160 bpm) or bradycardia (≤ 120 bpm), either two or three control cases (matched for maternal age and parity), with FHR > 120 bpm and < 160 bpm, were identified. Outcome variables assessed included: incidence of cesarean delivery, nuchal cord at delivery, meconium-stained amniotic fluid (AF), 5-min Apgar score < 7, fetal growth restriction (< 10th percentile for 41 weeks' gestation), meconium aspiration syndrome, and neonatal intensive care unit (NICU) admission. Statistical analysis included two-tailed t-test and X 2 test when appropriate, with p < 0.05 considered significant throughout. Results: During the study period 1390 post-term patients (6.81% of the general population) were assessed. Of these, 31 (2.23%) fetuses exhibited baseline FHR ≥ 160 bpm, and 76 fetuses (5.46%) exhibited baseline FHR ≤ 120 bpm. No significant differences were noted in the incidence of cesarean delivery, presence of nuchal cord at delivery, meconium-stained AF, 5-min Apgar scores < 7, fetal growth restriction, meconium aspiration syndrome, or the incidence of NICU admissions between the groups of patients with fetal tachycardia, bradycardia, and their respective controls. Conclusions: Uncomplicated baseline fetal tachycardia or bradycardia in post-term patients are not associated with an increase in the incidence of adverse perinatal outcome.

Our objective was to review current literature pertaining to prenatal ultrasonography of various fetal intracranial neoplastic and non-neoplastic tumors. To this goal, all manuscripts published in the English language regarding this topic obtained from a MEDLINE search from 1966 through January 1998 were selected and reviewed. Additional sources were identified through cross-referencing. Intracranial fetal tumors are extremely rare and precise diagnosis is dependent on histology examination of tissue obtained at subsequent surgery or autopsy. Currently, prenatal ultrasonographic findings associated with the following fetal intracranial tumors have been described: teratomas; neuroepithelial tumors including: glioblastoma, astrocytoma, gangliocytoma, medulloblastoma, choroid plexus, and papilloma; and mesenchymal tumors. Non-neoplastic fetal intracranial tumors are even less frequent and include: unilateral megalencephaly, heterotopia, and lipoma of the corpus callosum. Cardinal ultrasonographic findings associated with fetal intracranial tumors include: echogenic and semicystic space occupying lesions with or without distortion of normal symmetrical intracranial (usually midline) structures, calcifications, craniomegaly, polyhydramnios, obstructive hydrocephaly, high-output cardiac failure (hydrops fetalis), the presence of other associated structural anomalies, and infrequently abnormal cerebral Doppler flow velocimetry.

Sirenomelia represents a severe developmental field defect of the posterior axis caudal blastema, resulting in partial or complete fusion of the lower limb buds. The VATER association is a combination of morphological defects including vertebral defects, anal atresia, tracheoesophageal fistula, esophageal atresia, radial and renal anomalies. The VACTERL-H association is a rare expanded form of the VATER association that includes cardiac defects, limb defects, and hydrocephalus. It has been suggested that the VATER association may represent a less severe form of sirenomelia. In this report, we document a case in which prenatal ultrasonography detected simultaneously occurring sirenomelia and hydrocephalus. Postmortem radiography and autopsy findings confirmed the prenatal diagnosis. To our knowledge, this is the first report of prenatal diagnosis of a fetus with these two abnormalities. This report supports the hypothesis that VATER association, VACTERL-H association, and sirenomelia may represent pathophysiologically related entities.

Our objective was to determine the association of fetal breathing movements (FBM) within 24 hr of delivery, with the clinical diagnosis of chorioamnionitis and histologic evidence of severe acute amnionitis and umbilical-chorionic vasculitis in women delivering at < 32 weeks' gestation. We performed a cohort study of patients with singleton gestations delivered at < 32 weeks' following preterm labor with intact membranes and sonographically assessed biophysical profile within 24 hr of delivery (n = 111). Patients with FBM were compared with those without FBM, with regard to prevalence of clinical chorioamnionitis (CA) and histologic diagnosis of acute amnionitis and umbilical vasculitis. Maternal and neonatal charts were reviewed and the diagnosis of clinical CA made by previously established criteria. Histologic presence and extent of acute intrauterine inflammation was assessed and scored by a single pathologist blinded to clinical information. Results are presented as chi 2 values and odds ratios with 95% confidence intervals. Of the patients included in the study, FBM were absent in 56 and present in 55. The prevalence of CA was 13% (15 of 111), severe acute amnionitis 34% (38 of 111), and severe umbilical vasculitis 23% (26 of 111). Severe umbilical vasculitis was significantly less frequent in cases with FBM as compared to cases without FBM (15% [8 of 55] vs. 32% [18 of 56], p = 0.049). However, the difference in rate of CA (22% [12 of 55] vs. 34% [19 of 56], p = 0.22) and histologic severe amnionitis (29% [16 of 55] vs. 39% [22 of 56], p = 0.4) between cases with and without FBM was not significant. In the presence of preterm labor with intact membranes, absence of FBM had sensitivities of 73 and 72%, and specificities of 54 and 56% in the prediction of CA and histologic evidence of umbilical vasculitis, respectively. We conclude that absence of FBM is associated with histologic evidence of fetal inflammation in intrauterine infection in patients with preterm labor and intact membranes delivering at < 32 weeks. However, the low positive predictive value of absent FBM in predicting fetal inflammation in intrauterine infection should discourage the guidance of clinical management in patients < 32 weeks' gestation with preterm labor and intact membranes.

The objective of this study was assess whether residual amniotic fluid volume (AFV) following premature rupture of the membranes (PROM) is associated with fetal presentation, or the prevalence of either clinical or histologic infection in patients delivering below 32 weeks' gestation. From an established database of 465 deliveries below 32 weeks' gestation, patients with singleton, nonanomalous fetuses with AFV assessment within 24 hours of delivery were studied (n = 146). Fetal presentation was confirmed by ultrasound identifying 46 breech and 100 vertex-presenting fetuses. Premature rupture of the membranes was diagnosed by sterile speculum examination. Clinical chorioamnionitis was diagnosed by previously published criteria. Histopathology examination of the extraplacental amnion and the umbilical cord were performed by a single pathologist blinded to clinical data. Outcome variables evaluated: rupture-to-delivery interval, gestational age at delivery, neonatal morbidity parameters (1- and 5-min Apgar scores5 and 7, respectively; incidence of respiratory distress syndrome; bronchopulmonary dysplasia; retinopathy of prematurity; neonatal sepsis; intraventricular hemorrhage; days of ventilation; and hospitalization), and placental histologic parameters of maternal and/or fetal acute inflammation. Statistical analysis included contingency tables and analysis of variance with p.05 considered significant, after corrections for multiple comparisons when appropriate. Residual AF volume following PROM was significantly lower in breech compared with vertex presentation (AFV = 0 in 20 vs. 34; AFV = 1 in 19 vs. 27; AFV = 2 in 7 vs. 39, respectively, p = .014). No significant difference was noted in the rupture-to-delivery interval, gestational age at delivery, neonatal morbidity parameters, or histologic evidence of maternal and/or fetal acute inflammation (50% vs. 42%, p.2) between gestations with breech or vertex presentations. The incidence of clinical chorioamnionitis was significantly lower in breech compared with vertex presentation (40% vs. 60%, p.05). We conclude that following PROM below 32 weeks' gestation, in breech-presenting fetuses, the residual AFV and incidence of clinical chorioamnionitis are significantly decreased compared with vertex-presenting fetuses.

This study was performed to assess the association of lack of mandibular movement as manifested by absent fetal swallowing and micrognathia in a nonrestrictive intrauterine environment. Over a 5-year period, 14 fetuses with sonographic findings of polyhydramnios (amniotic fluid index [AFI] more than 20 cm), absent mandibular movement, and a nonvisualized fetal stomach, all consistent with absent fetal swallowing, were followed. A group of 14 fetuses, each with polyhydramnios (AFI more than 20 cm), yet with sonographic detection of fetal swallowing, served as controls. All gravidas in both groups were normoglycemic throughout gestation. Subsequent mandibular development was assessed at delivery or autopsy. Analysis of the data revealed that in the study group, 12 of these infants were liveborn, and two were stillborn. Eleven of the liveborn infants had an early neonatal death. All 14 infants of the study group demonstrated micrognathia. None of the control infants (all of whom survived) had micrognathia. In conclusion, this study supports the concept that normal mandibular growth may depend on the presence of mandibular movement during intrauterine development.

We report a case of a patient who received nalbuphine during labor. The fetus was in an awake state, but when exposed to intravenous nalbuphine manifested quiet sleep. This suggest a physiological response and not a sign of fetal compromise.