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Objective: To confirm the identity and assess the prevalence and evolution of the fluid‐filled interhemispheric midline structure, thought to be the cavum veli interpositi (CVI), in fetuses at 11–14 weeks' gestation. Methods: This was a retrospective study of first‐trimester ultrasound scans performed at a single center over 3 months. Inclusion criteria were singleton pregnancies at 11–14 weeks' gestation with known neonatal outcome. Five experts reviewed the images. Mixed‐effects logistic regression and generalized estimating equations (GEE) were conducted to analyze the associations between the presence of the structure and variables including ultrasound approach (transabdominal vs transvaginal), maternal body mass index (BMI), gestational age, fetal crown–rump length (CRL) and biparietal diameter (BPD). Second‐trimester ultrasound scans of the fetal central nervous system at 18–24 weeks' gestation were evaluated for the persistence of the CVI in fetuses in which the structure was observed in the first trimester. Results: Of the 223 cases reviewed, 104 were included, among which the CVI was observed in 25 (24%) cases. There was no statistically significant difference in CVI visualization between transabdominal and transvaginal ultrasound examinations. GEE showed significant associations between the presence of the fetal structure and CRL (odds ratio (OR) per 10‐unit increase, 1.32; P < 0.0001) and BPD (OR per 10‐unit increase, 1.88; P = 0.0011). Maternal BMI and gestational age showed no significant effect on the presence of the CVI. At second‐trimester follow‐up of the 25 fetuses in which the CVI was observed initially, 44% still showed a CVI, 32% exhibited a cavum vergae, 4% had both structures and 20% had neither. Conclusions: Based on its anatomical location and, in some fetuses, its visualization as a distinct entity from the third ventricle, the identity of the interhemispheric midline structure in the suprathalamic region of the fetal brain between 11–14 weeks' gestation was confirmed as the CVI. The CVI and/or cavum vergae persisted into the second trimester in 80% of fetuses identified initially as having a CVI. Its presence is not linked to pathology, offering reassurance to practitioners and parents. © 2023 International Society of Ultrasound in Obstetrics and Gynecology. [ABSTRACT FROM AUTHOR]

Objective: The study's objective was to compare the efficacies of oral and intramuscular antenatal administration of dexamethasone in reducing neonatal respiratory distress syndrome.Study Design: Subjects at high risk for preterm delivery between 24 and 33 weeks' gestation were prospectively randomly assigned to receive either 6 mg intramuscular dexamethasone or 8 mg oral dexamethasone every 12 hours for 4 doses. The regimen was repeated weekly until 34 weeks' gestation if delivery had not yet occurred. A blinded data review was performed. The primary outcome of the trial was respiratory distress syndrome. Data were analyzed in an intent to treat fashion. Comparisons were made with an unpaired t test, chi2 or Fisher exact test, and survival analysis. P <.05 was considered significant.Results: The study was discontinued at 39% enrollment after a blinded review of available outcomes. A total of 170 women with 188 fetuses were randomly assigned. The oral and intramuscular groups had similar mean gestational ages at enrollment (29.9 weeks vs 29.2 weeks) and similar median latencies (9.5 vs 10 days). No difference in the frequency of respiratory distress syndrome was found between the oral and intramuscular groups, (34.3% vs 29.8%). Neonatal sepsis (10.1% vs 1.2%, P =.01) and intraventricular hemorrhage (10.1% vs 2. 4%, P =.04) were significantly higher in the oral group. There were no statistical differences in the frequencies of necrotizing enterocolitis or neonatal death. A subgroup analysis of 112 patients who were delivered at <34 weeks' gestation revealed no statistical difference in respiratory distress syndrome between the groups; however, oral dexamethasone was associated with a significant increase in sepsis (15.9% vs 1.6%, P =.009) and intraventricular hemorrhage (15.9% vs 3.3%, P =.03).Conclusion: Oral administration increases neonatal morbidity without demonstrable benefit and should not at this time be used clinically for induction of fetal pulmonary maturation. [ABSTRACT FROM AUTHOR]

Objectives: Vascular tone is controlled largely by the sympathetic nervous system and is modulated by neuropeptide Y. Preeclampsia is linked to sympathetic overactivity. Nitric oxide can cause vasorelaxation of vessels or decrease sympathetic outflow by activating the baroreceptor reflex. Our purpose in this study was to compare serum levels of neuropeptide Y and nitrite levels in normotensive and preeclamptic gravid women.Study Design: Twelve preeclamptic and 12 normotensive women matched for race, body mass index, parity, and gestational age were studied. Neuropeptide Y was measured by using a commercial radioimmunoassay. Nitric oxide was converted to nitrite by using metallic cadmium, and nitrite levels were determined spectrophotometrically by using a colorimetric assay. Data are presented as mean +/- SEM and were compared by using a t test.Results: Neuropeptide Y levels were similar among preeclamptic and normotensive gravid women (33.8 +/- 3.0 and 32.2 +/- 3 pg/mL, respectively). Similarly, there were no differences in nitrite concentrations between preeclamptic and normotensive patients (11.6 +/- 0.8 vs 11.2 +/- 0.4 micromol/L, respectively). We also examined the ratios of neuropeptide Y and nitrite and found no correlation between preeclamptic and normotensive women.Conclusion: Peripheral levels of neuropeptide Y or nitrite do not correlate with preeclampsia. Assessment of sympathetic overactivity in preeclampsia requires an alternate model. [ABSTRACT FROM AUTHOR]

Objectives: Unconjugated estriol production depends on fetal adrenal androgen precursors. Fetal exposure to exogenous glucocorticoids results in adrenal suppression with a subsequent decrease in maternal serum unconjugated estriol levels. We compared the efficacy between oral and intramuscular dexamethasone in maternal serum unconjugated estriol suppression at 48 hours after the initial dose among women at risk for preterm delivery.Study Design: Twenty-four gravidas at risk for preterm delivery were randomized to receive either 6 mg intramuscular or 8 mg oral dexamethasone every 12 hours for a total of 4 doses. Blood samples (9 mL) were obtained before the initial dexamethasone administration and again after the fourth dose. Serum was separated and frozen at -70 degreesC and subsequently underwent batch analysis. Unconjugated estriol levels were determined by radioimmunoassay with intra-assay and interassay coefficients of variation of 7.9% and 5.5%, respectively. All values are reported as mean +/- SD. The primary statistical analysis was a t test, with P <.05 considered significant.Results: At the time of dexamethasone administration, gestational ages in both groups were similar. Predexamethasone and postdexamethasone unconjugated estriol levels were also similar between the intramuscular and oral groups (5.39 +/- 3.99 vs 1.80 +/- 2.49 ng/mL and 6.05 +/- 3.00 vs 1.61 +/- 1.03 ng/mL, respectively, P >.05). No difference in percent decrease in unconjugated estriol levels was found between the intramuscular (0.67 +/- 0.24) and oral (0.65 +/- 0.39) groups.Conclusion: Oral dexamethasone (8 mg) produces similar maternal serum unconjugated estriol suppression compared with intramuscular dexamethasone (6 mg) when evaluated 48 hours after administration. [ABSTRACT FROM AUTHOR]

Pancreatic beta cells are among the slowest replicating cells in the human body and have not been observed to increase in number except during the fetal and neonatal period, in cases of obesity, during puberty, as well as during pregnancy. Pregnancy is associated with increased beta cell mass to meet heightened insulin demands. This phenomenon raises the intriguing possibility that factors present in the serum of pregnant individuals may stimulate beta cell proliferation and offer insights into expansion of the beta cell mass for treatment and prevention of diabetes. The primary objective of this study was to test the hypothesis that serum from pregnant donors contains bioactive factors capable of inducing human beta cell proliferation. An immortalized human beta cell line with protracted replication (EndoC-βH1) was cultured in media supplemented with serum from pregnant and non-pregnant female and male donors and assessed for differences in proliferation. This experiment was followed by assessment of proliferation of primary human beta cells. Sera from five out of six pregnant donors induced a significant increase in the proliferation rate of EndoC-βH1 cells. Pooled serum from the cohort of pregnant donors also increased the rate of proliferation in primary human beta cells. This study demonstrates that serum from pregnant donors stimulates human beta cell proliferation. These findings suggest the existence of pregnancy-associated factors that can offer novel avenues for beta cell regeneration and diabetes prevention strategies. Further research is warranted to elucidate the specific factors responsible for this effect.

Preterm birth is the principal contributor to neonatal death and morbidity worldwide. We previously described a plasma cell-free RNA panel that between 16 and 20 weeks of pregnancy had potential to predict spontaneous preterm birth (sPTB) ≤ 32 weeks caused by preterm labor (PTL) or preterm premature rupture of membranes (PPROM). The present study had three objectives: (1) estimate the RNA panel prognostic accuracy for PTL/PPROM ≤ 32 weeks in a larger series; (2) improve accuracy by adding clinical characteristics to the predictive model; and (3) examine the association of the RNA panel with preeclampsia. We studied 289 women from Memphis TN prospectively sampled 16.0-20.7 weeks and found: (1) PSME2 and Hsa-Let 7g were differentially expressed in cases of PTL/PPROM ≤ 32 weeks and together provided fair predictive accuracy with AUC of 0.76; (2) combining the two RNAs with clinical characteristics improved good predictive accuracy for PTL/PPROM ≤ 32 weeks (AUC 0.83); (3) NAMPT and APOA1 were differentially expressed in women with 'early-onset preeclampsia' (EOP) and together provided good predictive accuracy with AUC of 0.89; and (4) combining the two RNAs with clinical characteristics provided excellent predictive accuracy (AUC 0.96). Our findings suggest an underlying common pathophysiological relationship between PTL/PPROM ≤ 32 weeks and EOP and open inroads for the prognostication of high-risk pregnancies.

Introduction: Cardiovascular disease (CVD) remains the leading cause of death among women. Adverse pregnancy outcomes (APOs), including pre-eclampsia (PE), gestational diabetes mellitus (GDM) and pre-term birth (PTB) are associated with future maternal CVD risk. However, data on awareness of the association between APOs and long-term CVD risk among physicians in different specialties are lacking. This study assessed awareness of this association and whether this knowledge varies by specialty., Methods: An anonymous web-based voluntary survey was sent to physicians in internal medicine (IM), family medicine (FM), obstetrics-gynecology (Ob-Gyn) and cardiology. The questions aimed to assess a physician's knowledge regarding identification of APOs and their association with future CVD risk and knowledge of CVD risk factor screening in women with APOs and future CVD risk., Results: The survey was completed by 53 physicians, of whom 21% were in IM, 26% in FM, 23% in Ob-Gyn and 30% in cardiology. Based on the responses, cardiologists screened most frequently for APOs, with 56% always screening a female patient and 31% often screening. Only half of the IM and FM physicians acknowledged awareness of the association between APOs and CVD risk. Respondents in all specialties recognized PE and GDM as APOs linked to long-term maternal CVD risk, but failed to associate PTB as an APO. The majority of physicians in IM, FM and cardiology also lacked the knowledge of how often to appropriately screen for CVD risk factors associated with APOs., Conclusion: Awareness of the association between APO and future maternal CVD risk varies by specialty. A significant percentage of the physicians who responded to the survey did not routinely ask about APOs when assessing CVD risk and failed to identify PTB as a risk factor for APOs. Education on this topic and targeted efforts to improve screening for APOs are needed within all specialties to help reduce CVD morbidity and mortality., (© 2021. The Author(s).)

Objective: To compare the second-trimester plasma cell-free (PCF) transcriptome of women who delivered at term with that of women with spontaneous preterm birth (sPTB) at or before 32 weeks of gestation and identify/validate PCF RNA markers present by 16 weeks of gestation., Design: Prospective case-control study., Setting: Academic tertiary care centre., Population: Pregnant women with known outcomes prospectively sampled., Methods: PCF RNAs extracted from women at 22-24 weeks of gestation (five sPTB up to 32 weeks and five at term) were hybridised to gene expression arrays. Differentially regulated RNAs for sPTB up to 32 weeks were initially selected based on P value compared with control (P < 0.01) and fold change (≥1.5×). Potential markers were then reordered by narrowness of distribution. Final marker selection was made by searching the Metacore™ database to determine whether the PCF RNAs interacted with a reported set of myometrial Preterm Initiator genes. RNAs were confirmed by quantitative reverse transcription polymerase chain reaction and tested in a second group of 40 women: 20 with sPTB up to 32 weeks (mean gestation 26.5 weeks, standard deviation ±2.6 weeks), 20 with spontaneous term delivery (40.1 ± 0.9 weeks) sampled at 16-19 +5  weeks of gestation., Main Outcome Measure: Identification of PCF RNAs predictive of sPTB up to 32 weeks., Results: Two hundred and ninety-seven PCR RNAs were differentially expressed in sPTB up to 32 weeks of gestation. Further selection retained 99 RNAs (86 mRNAs and 13 microRNAs) and five of these interacted in silica with seven Preterm Initiator genes. Four of five RNAs were confirmed and tested on the validation group. The expression of each confirmed PCF RNA was significantly higher in sPTB up to 32 weeks of gestation. In vitro study of the four mRNAs revealed higher expression in placentas of women with sPTB up to 32 weeks and the potential to interfere with myometrial quiescence., Conclusions: The PCF RNA markers are highly associated with sPTB up to 32 weeks by 16 weeks of gestation., Tweetable Abstract: Women destined for spontaneous preterm birth can be identified by 16 weeks of gestation with a panel of maternal plasma RNAs., (© 2021 John Wiley & Sons Ltd.)

While non-alcoholic fatty liver disease (NAFLD) is associated with increased risk of impaired glucose tolerance and type 2 diabetes mellitus (DM) in non-pregnant patients, the clinical significance of NAFLD during pregnancy is still unclear. We hypothesized that sonographic findings of NAFLD during pregnancy would be associated with gestational diabetes mellitus (GDM) and predict abnormal postpartum glucose metabolism. NAFLD was assessed by ultrasound during and after pregnancy. Standard 2-hour 75 g oral glucose tolerance test (OGTT) was used during pregnancy and post partum to establish GDM and the diagnosis of normal, impaired fasting glucose, or DM. We also measured plasma insulin, C peptide, and free fatty acids (FFA) concentration during an OGTT to evaluate glucose tolerance, insulin secretion and insulin resistance. Of the 84 subjects, 12 had sonographic evidence of NAFLD (5 of whom had OGTT post partum). There was a non-significant trend toward higher mean weight and body mass index during and after gestation in the NAFLD group, but no statistically significant differences in mean age, ethnicity, prepregnancy and postpregnancy hemoglobin A1C values, and postpartum levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), glucose, insulin, or FFA. We did not find an association between sonographic evidence of NAFLD during the third trimester of pregnancy and abnormal glucose metabolism during or after pregnancy. This study also suggests that while AST and ALT are not reliable diagnostic tools for NAFLD during the postpartum period, ultrasound is a reasonably safe, practical, and cost-effective modality to assess maternal hepatic fat during pregnancy., Competing Interests: Competing interests: None declared., (© American Federation for Medical Research 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Diabetes in pregnancy increases the risk of adverse maternal, obstetric, fetal, and neonatal outcomes. Internists can reduce these risks by optimizing glycemic control before conception and providing effective counseling on strategies to reduce the risks associated with pregnancy and diabetes. Routine screening of reproductive-age women with diabetes should include a comprehensive physical examination and laboratory tests to identify at-risk patients and begin strategic management. A review of medications for teratogenic potential is also needed., (Copyright © 2018 Cleveland Clinic.)

Background: Fetal tachycardia is attributable to a variety of etiologies, including an untreated maternal medical condition or an indicator of potential fetal compromise. Maternal medication administration may also affect the fetal heart rate., Case: A 28-year-old nulliparous patient at 41 weeks of gestation was treated for pruritus with intravenous diphenhydramine after epidural administration of fentanyl. Within 14 minutes, the fetal heart rate increased from a baseline of 155 beats per minute (bpm) to more than 200 bpm while maintaining moderate variability. This was accompanied by an increase in uterine contractions occurring every 1.5 minutes. The fetal tachycardia lasted 51 minutes; several hours later, a healthy neonate was delivered., Conclusion: Diphenhydramine may produce transient fetal tachycardia as well as increased maternal uterine activity.

Background: Application of latent variable models in medical research are becoming increasingly popular. A latent trait model is developed to combine rare birth defect outcomes in an index of infant morbidity., Methods: This study employed four statewide, retrospective 10-year data sources (1999 to 2009). The study cohort consisted of all female Florida Medicaid enrollees who delivered a live singleton infant during study period. Drug exposure was defined as any exposure to Antiepileptic drugs (AEDs) during pregnancy. Mothers with no AED exposure served as the AED unexposed group for comparison. Four adverse outcomes, birth defect (BD), abnormal condition of new born (ACNB), low birth weight (LBW), and pregnancy and obstetrical complication (PCOC), were examined and combined using a latent trait model to generate an overall severity index. Unidimentionality, local independence, internal homogeneity, and construct validity were evaluated for the combined outcome., Results: The study cohort consisted of 3183 mother-infant pairs in total AED group, 226 in the valproate only subgroup, and 43,956 in the AED unexposed group. Compared to AED unexposed group, the rate of BD was higher in both the total AED group (12.8% vs. 10.5%, P < .0001), and the valproate only subgroup (19.6% vs. 10.5%, P < .0001). The combined outcome was significantly correlated with the length of hospital stay during delivery in both the total AED group (Rho = 0.24, P < .0001) and the valproate only subgroup (Rho = 0.16, P = .01). The mean score for the combined outcome in the total AED group was significantly higher (2.04 ± 0.02 vs. 1.88 ± 0.01, P < .0001) than AED unexposed group, whereas the valproate only subgroup was not., Conclusions: Latent trait modeling can be an effective tool for combining adverse pregnancy and perinatal outcomes to assess prenatal exposure to AED, but evaluation of the selected components is essential to ensure the validity of the combined outcome.

Background: Although vertebral hemangiomas are found in 10% of the population, they rarely become symptomatic. We describe management of an enlarging cervical vertebral hemangioma during pregnancy., Case: A primiparous woman at 33 weeks of gestation presented with neck pain and paresthesias. She had a known cervical hemangioma. Imaging revealed a C6-C7 hemangioma with extradural extension. Her symptoms fluctuated, and she was delivered by cesarean at 36 weeks of gestation. Improvement occurred after delivery, and radiographic regression of the hemangioma was demonstrated., Conclusion: Hormonal and vascular changes of pregnancy may exacerbate spinal hemangiomas. Depending on the location, these may lead to profound neurologic disability and management depends on the degree of myelopathy. Surgical intervention may be necessary to avoid neurologic injury, but amelioration after delivery is possible.

Septic arthropathy leads to rapid joint destruction, impairment, and disability. Staphylococcus can be particularly virulent to bone and joints leading to adverse obstetric events. At 28 of weeks gestation, a patient presented with pyelonephritis and progressive left shoulder pain. Magnetic resonance imaging indicated early clavicular destruction and acromial involvement. Glenohumeral joint aspiration produced Staphylococcus aureus. The patient then had premature rupture of membranes and progressed rapidly to preterm delivery. Placental pathology revealed chorioamnionitis and microabscesses. Treatment of the infected joint required further surgical drainage and bone resection as well as extended antibiotics. It is important to remember that joint pain in pregnancy may indicate infective arthritis, and pyelonephritis can be a source of such an infection. Evaluation includes magnetic resonance imaging and consultation for joint aspiration. Prompt recognition and treatment are necessary to prevent joint destruction.

Objective: Gestational diabetes (GDM) and obesity portend a high risk for subsequent type 2 diabetes. We examined maternal factors influencing the development of gestational diabetes (GDM) in obese women receiving 17-alpha-hydroxyprogesterone caproate (17OHPC) for preterm delivery prevention., Materials and Methods: Retrospectively identified were 899 singleton pregnancies with maternal prepregnancy body mass indices of ≥30 kg/m(2) enrolled for either 17OHPC weekly administration (study group) or daily uterine monitoring and nursing assessment (control group). Patients with history of diabetes type 1, 2, or GDM were excluded. Maternal characteristics were compared between groups and for women with and without development of GDM. A logistic regression model was performed on incidence of GDM, controlling for significant univariate factors., Results: The overall incidence of GDM in the 899 obese women studied was 11.9%. The incidence of GDM in the study group (n = 491) was 13.8% versus 9.6% in the control group (n = 408) (P = 0.048). Aside from earlier initiation of 17OHP and advanced maternal age, other factors including African American race, differing degrees of obesity, and use of tocolysis were not significant risks for the development of GDM., Conclusion: In obese women with age greater than 35 years, earlier initiation of 17OHPC may increase the risk for GDM.

Successful airway management of an infant or child with moderate to severe retrognathia first requires recognition of a potential problem. If the child cannot be intubated in a standard fashion, the use of a laryngeal mask airway (LMA) should be considered. We describe two cases wherein a toddler and an infant with severe retrognathia failed multiple attempts at traditional intubation. Both had an anterior larynx and hypoplasia of the mandible. In both cases, a subsequent LMA was successfully placed. The severely retrognathic newborn or child presents to the physician a unique challenge in airway management. Techniques to manage this difficult pediatric airway are different from those used in the adult. Otolaryngologists should be aware of this intubation technique and include it in their armamentarium of airway-management strategies. The LMA is not recommended as the technique of choice for securing a difficult airway, but it is an effective alternative when indicated, and it might be life-saving.

Objective: The purpose of this study was to compare the perinatal outcomes of women after diagnosis of gestational diabetes by the current American College of Obstetricians and Gynecologists-National Diabetes Data Group recommendations with outcomes after diagnosis by the American Diabetes Association criteria., Study Design: We identified records of 242 women who had had the standard 3-hour oral glucose tolerance test between 1995 and 1999 at the Regional Medical center in Memphis. Patients were categorized into 1 of 3 groups as follows: euglycemic control subjects (n = 69), subjects with gestational diabetes diagnosed by the National Diabetes Data Group criteria (n = 130), and subjects with gestational diabetes diagnosed by the American Diabetes Association criteria (n = 43). Maternal and infant charts were reviewed. Primary outcomes included frequency of cesarean delivery, preeclampsia, and macrosomia. In univariate analysis the chi2 test was used to compare group differences, and in multivariate analysis we used stepwise logistic regression and controlled for confounding factors., Results: No differences existed among the 3 groups regarding maternal race, body mass index, history of preeclampsia, or family history of diabetes. The frequency of overall cesarean delivery, of cesarean delivery for macrosomia or arrest disorder, of preeclampsia, and of macrosomia did not differ significantly among the 3 groups. Neonatal hypoglycemia was more frequent in the groups with a diagnosis by the American Diabetes Association criteria (23.3%) and by the National Diabetes Data Group criteria (16.2%) than in the control subjects (7.2%), reaching near significance (P =.057). In the multivariate analysis, cesarean delivery for macrosomia or an arrest disorder correlated negatively with parity and positively with body mass index. Preeclampsia was associated with African American race and body mass index; macrosomia correlated with a history of macrosomia and familial diabetes. Neonatal hypoglycemia was more common in the American Diabetes Association group (odds ratio, 2.45; 95% confidence interval, 1.004-5.97) and in the insulin-requiring National Diabetes Data Group category (odds ratio, 3.71; 95% confidence interval, 1.20-11.44)., Conclusion: The benefits of defining an additional high-risk population of women with gestational diabetes by the American Diabetes Association criteria are unclear. Further large-scale prospective clinical trials are required.

Toxoplasmosis is caused by the protozoan organism, Toxoplasma gondii. Infection with this organism primarily results from contact with infected cats and from ingestion of improperly cooked meat. Most adults with toxoplasmosis are asymptomatic. When symptoms are present, they typically resemble a mononucleosis or flulike illness. The diagnosis of toxoplasmosis in the pregnant adult is best made using serological techniques to detect IgM antibody and to document significant changes in the IgG antibody titer. Congenital toxoplasmosis usually occurs as a result of primary maternal infection. The most useful tests for confirmation of fetal infection are ultrasound examination, cordocentesis for detection of IgM-specific antibody, and amniocentesis for detection of toxoplasma DNA in amniotic fluid. Congenital toxoplasmosis can be treated with reasonable success by administration of antibiotics (spiramycin, sulfadiazine, and pyrimethamine) to the mother. In an effort to prevent acquisition of infection, pregnant women should be counseled to avoid contact with cat litter and improperly cooked beef, pork, or lamb.

Five cases of prenatally detected neck masses that had a potential for airway obstruction at birth are described. The various options for management of the airway are discussed, including using maternal-fetal circulation until intubation, rigid bronchoscopy, tracheotomy, cyst aspiration, or extracorporeal membrane oxygen support. Congenital abnormalities involving the fetal face or neck are extremely rare. With technical advances in ultrasonography, these masses were first noted on prenatal ultrasound in the late 1970s. Before that period, they were detected at delivery. These masses are solid or cystic and may cause asphyxia because of airway obstruction at the time of delivery. The survivability of these neonates without immediate intervention at birth is 0% to 20%. If a neck mass is detected in the fetus by prenatal ultrasonography, then a strategic plan for these types of cases should be developed early in the prenatal period. The airway management plan should be tailored for each individual case. Coordination and the expertise of an obstetrician, neonatologist, anesthesiologist, and pediatric otolaryngologist are needed to manage these complex situations.

Objective: Our purpose was to investigate the problems encountered in the diagnosis and management of cerebrovascular disorders associated with pregnancy and the puerperium., Study Design: Pregnancies complicated by cerebrovascular disorders were identified by retrospective chart review (1985 to 1995). Events associated with trauma, neoplasm, drug ingestion, and infection were excluded., Results: The study population comprised 24 women with a variety of cerebrovascular disorders: 14 with infarction (5 arterial, 9 venous), 6 with intracranial hemorrhage (3 anatomic malformation, 3 unknown etiology), 3 with hypertensive encephalopathy, and 1 with an unruptured aneurysm. Blood pressure reflected physical condition at presentation and did not predict diagnosis or outcome except in the 3 women with hypertensive encephalopathy. Only 4 of 14 women with infarction and 1 of 6 with intracranial hemorrhage had a diastolic blood pressure > or = 110 mm Hg. Presumption of eclampsia delayed the diagnosis in 10 women (41.7%). In addition, patient delay in seeking medical attention complicated 10 cases. After review, none of the adverse maternal outcomes were deemed preventable by earlier physician intervention. Seven maternal deaths occurred (29.2%). Neonatal outcome was related to the gestational age and the maternal condition at presentation., Conclusion: Cerebrovascular disorders are an uncommon and unpredictable complication of pregnancy that are associated with substantial maternal and fetal mortality. Suspected eclampsia unresponsive to magnesium sulfate therapy warrants an immediate neuroimaging study. Interestingly, in women with intracranial hemorrhage, severe hypertension was not an associated predictive factor.

Objective: To compare the bioavailability of oral and intramuscular (i.m.) dexamethasone in third-trimester pregnant women., Methods: Oral and i.m. dexamethasone levels were compared in a randomized, parallel, crossover bioavailability study involving 11 gravid women in the third trimester of pregnancy. Subjects were randomized to receive either 6 mg of i.m. or 8 mg of oral dexamethasone. The following week, the alternative regimen was administered. Serial blood samples were obtained after drug administration. Dexamethasone concentrations were measured by radioimmunoassay. Total area under the curve was compared for the oral and i.m. groups using a paired t test., Results: Eight of the 11 women completed the study through 12 hours; all 11 women completed the study through 6 hours. Among the 11 women, peak levels of dexamethasone occurred 30 minutes after i.m. injection (mean +/- standard deviation, 101.7 +/- 19.2 ng/mL) and 120 minutes after oral administration (65.9 +/- 20.5 ng/mL). Area under the curve did not differ significantly between those receiving i.m. dexamethasone (258.3 +/- 50.0 ng/minute/mL) and those receiving oral dexamethasone (251.8 +/- 59.7 ng/minute/mL) when measured 6 hours after administration of the drug. Terminal half-lives were similar in the i.m. and oral groups. Similar findings were noted among the eight women who were studied through 12 hours. This study had a power of 87% to detect a 20% difference in area under the curve between the two groups., Conclusion: The bioavailability of 8 mg of oral dexamethasone is similar to that of a 6-mg IM dose, as determined by the area under the curve.