Faculty Bibliography

BACKGROUND:Pyogenic granulomas are benign vascular lesions of the skin or mucous membranes. Oral lesions are believed to occur in up to 2% of pregnancies. To the best of our knowledge, non-oral lesions in pregnancy have not been reported in the obstetric literature. CASES/METHODS:We report two cases of non-oral pyogenic granuloma in pregnancy. The first, involving a finger lesion in a woman with triplets, demonstrated rapid growth and recurred after surgical excision. The second was an inguinal crease lesion, which was excised successfully after becoming symptomatic. CONCLUSION/CONCLUSIONS:Clinical experience suggests that the prevalence of pyogenic granulomas in pregnancy is not as high as has been reported in the literature. The relation of non-oral lesions to pregnancy is unknown.

A prospective study was conducted to evaluate the ability of the transverse cerebellar diameter/abdominal circumference ratio to identify growth-retarded fetuses. Of the cases analyzed, 48 of 87 (55%) were growth retarded by birth weight. The transverse cerebellar diameter/abdominal circumference ratio identified growth retardation with a sensitivity of 71%, specificity of 77%, positive predictive value of 79%, and negative predictive value of 68%. Fourteen growth-retarded fetuses were missed by the ratio; however, 57% of the missed cases were severely growth retarded. The transverse cerebellar diameter/abdominal circumference ratio can be useful for the assessment of fetal growth retardation; however, the ratio may be normal in cases of severe fetal growth retardation.

Retroversion of the first trimester uterus occurs in 6 to 19 per cent of all pregnancies and usually does not cause problems. If the uterus remains retroverted as the pregnancy advances, it may become wedged into the pelvic cavity. This complication is referred to as uterine incarceration which can lead to spontaneous abortion, preterm labor, uterine dystocia, and inadvertent incision into the cervix or the bladder during cesarean section in cases of unrecognized incarceration. Seven cases of uterine incarceration are presented with a detailed review including clinical signs and symptoms, physical findings, ultrasound findings, and treatment modalities for each stage of pregnancy. Moreover, we present a new method of treatment for second trimester uterine incarceration.

Abnormal fetal biometry is considered a marker for fetal trisomy. We prospectively evaluated the biparietal diameter/femur length ratio to identify Down syndrome fetuses. This ratio was calculated when women (< 35 years old) underwent an amniocentesis for an abnormal biochemical screen for Down syndrome. Using reported ratio cut-offs (> 1.5 SD above the mean), the ratio had a sensitivity of 50% (3/6), specificity of 92% (244/264), positive predictive value of 13% (3/23), negative predictive value of 99% (244/247), and a relative risk of 10.8. Using our own population ratio, a cut-off > 1.5 SD had a sensitivity of 50% (3/6), specificity of 94% (249/252), positive predictive value of 17% (3/18), negative predictive value of 99% (249/252) and a relative risk of 13.9. A lower cut-off decreased the efficacy to detect Down syndrome. A ratio > 1.5 SD above the mean is a useful adjunct to identify Down syndrome in pregnancies at risk by an abnormal biochemical screen.

OBJECTIVE:The null hypothesis is that intravenous magnesium sulfate does not affect the biophysical profile of the healthy preterm fetus. STUDY DESIGN/METHODS:Thirty-one fetuses of 25 patients between the gestational ages of 24 and 35 weeks, median 31.4 and mean (+/- SD) 30.4 (+/- 2.9), who required tocolysis for uterine contractions were prospectively studied. After normal fetal biophysical assessment was documented, intravenous magnesium sulfate was started as a 4 or 6 gm loading dose and then infused at 2 to 3.5 gm/hr to achieve tocolysis. Blood was drawn for measurement of maternal serum magnesium levels immediately before intravenous magnesium sulfate was administered and at 2 and 12 hours after the loading dose. Biophysical profiles, consisting of a possible 12 points, were performed at the same time as blood was drawn. Serum magnesium levels were compared with one-way analysis of variance for repeated measures and biophysical profile scores with Friedman's test. Statistical significance was considered p < 0.05. RESULTS:Mean (+/- SD) serum magnesium levels were 1.7 (+/- 0.1) mg/dl before infusion, 4.3 (+/- 0.6) mg/dl at 2 hours, and 5.2 (+/- 0.7) mg/dl at 12 hours (p < 0.001). Six fetuses did not have a 12-hour biophysical profile; three were delivered for severe variable decelerations, two progressed in labor, and in one tocolysis was discontinued. The median biophysical profile score was 11 before intravenous magnesium sulfate, at 2 hours, and at 12 hours after the loading dose. The biophysical parameters present and the percentage of fetuses with each parameter were as follows: breathing (> 30 seconds), 88% (22/25) before magnesium sulfate, 84% (21/25) at 2 hours, and 92% (23/25) at 12 hours; nonstress test (reactive), 84% (21/25) before magnesium sulfate, 68% (17/25) at 2 hours, and 80% (20/25) at 12 hours; movement (normal), 100% (25/25) before magnesium sulfate, 100% (25/25) at 2 hours, and 96% (24/25) at 12 hours. CONCLUSION/CONCLUSIONS:Intravenous magnesium sulfate did not significantly alter the biophysical profile in the 25 fetuses evaluated by three biophysical profiles in spite of the significant increase in maternal serum magnesium levels.

OBJECTIVE: This retrospective study was conducted to determine whether predischarge survival and morbidity of very-low-birth weight infants varied according to the principal pregnancy complication that led to preterm delivery. STUDY DESIGN: The hospital records of 535 consecutive live-born singleton infants who weighed between 500 and 1499 gm were reviewed, and five primary complications that resulted in preterm delivery were identified: (1) premature rupture of membranes (n = 244, 46%), (2) idiopathic preterm labor (n = 97, 18%), (3) antepartum hemorrhage (n = 58, 11%), (4) pregnancy-induced hypertension (n = 98, 18%), and (5) 'other' complications (n = 38, 7%). Neonatal records were studied to identify the presence of respiratory distress syndrome, bronchopulmonary dysplasia, pulmonary interstitial emphysema, patent ductus arteriosus, necrotizing enterocolitis, intraventricular hemorrhage, retinopathy of prematurity, and infant death before hospital discharge. Logistic regression analysis was used to analyze the association of each pregnancy complication with the various forms of neonatal morbidity. RESULTS: There were no statistically significant differences in discharge survival rates (range 71% to 88%) among infants born to women who experienced one of the five types of primary complications. Independent of all confounders, premature rupture of membranes was associated with a decreased risk of respiratory distress syndrome, bronchopulmonary dysplasia, pulmonary interstitial emphysema, patent ductus arteriosus, and intraventricular hemorrhage. Preterm labor was associated with an increased risk of pulmonary interstitial emphysema, patent ductus arteriosus, and intraventricular hemorrhage. Pregnancy-induced hypertension was associated with an increased risk of respiratory distress syndrome, pulmonary interstitial emphysema, and patent ductus arteriosus. Antepartum hemorrhage was associated with an increased risk of patent ductus arteriosus. CONCLUSION: The principal pregnancy complication that led to preterm delivery significantly influenced predischarge morbidity but not the predischarge survival of live-born infants

OBJECTIVE: The aim of this study was to evaluate placental abnormalities in relation to birth weight discordance in dichorionic and monochorionic twins. STUDY DESIGN: The maternal charts and placental abnormalities of 147 structurally normal twin pairs with cords labeled at delivery were reviewed. The placental weight belonging to each twin was determined by measuring the length, width, and thickness in each of the two placental disks. Placental weight, chorionicity, infarction, abruptio placentae, decidual vascular abnormality, villous fibrosis and hypovascularity, chronic villitis, and intraplacental thrombi were also assessed. Birth weight was discordant if > or = 20%. The data were analyzed with chi 2 and analysis of variance after log transformation of skewed discordancy values. RESULTS: Of the 147 twin pairs, 99 were dichorionic and 48 monochorionic. Placental weights were known for 91 dichorionic and 40 monochorionic twins. Of the lighter cotwins in dichorionic twin pairs 36.3% (33/91) belonged to the heavier placenta, 49.5% (45/91) belonged to the lighter placenta, and 14.3% (13/91) had an equal share of the placental weight with the heavier sibling (p < 0.05). In 42.4% (42/99) the lighter dichorionic twin had more placental lesions than the heavier twin, in 38.4% (38/99) the same number of lesions were present in both placentas, and in 19.2% (19/99) the heavier twin had more placental lesions. There was linear correlation between percent discordance and number of placental lesions in the lighter twin. In dichorionic twins 18 of the 99 (18.1%) were discordant. In 77.8% (14/18) the lighter twin had more placental lesions than the heavier twin, in 16.7% (3/18) the number of lesions was the same in both, and in 5.6% (1/18) the heavier twin had one more lesion than the lighter twin (p < 0.05). In monochorionic twins, regardless of birth weight discordance, no differences in placental abnormalities were observed. CONCLUSIONS: In dichorionic twins significant birth weight discordance was attributable not to differences in placental weight but to a greater number of placental lesions in the lighter twin than in the heavier twin (p < 0.05). This did not hold true for monochorionic twins

A case of combined pentalogy of Cantrell with sirenomelia in a monozygotic twin is described. Similar cases from the world literature are reviewed. Current concepts on the etiology of anterior midline ventral wall defects and sirenomelia are detailed. It has been proposed that anterior midline ventral wall defects may be caused by either monozygotic twinning or vascular dysplasia. Likewise, a vascular steal phenomenon causes sirenomelia. A common etiology for these defects, an alteration in vascular development, is proposed

OBJECTIVE:To determine whether continuous intrapartum electronic fetal heart rate monitoring (EFM) is associated with decreased perinatal mortality and morbidity compared with intermittent auscultation. METHODS:The study was conducted simultaneously at two university hospitals in Athens, Greece (Alexandra and Marika Iliadi Hospitals) from October 1, 1990 to June 30, 1991. All patients with singleton living fetuses and gestational ages of 26 weeks or greater were eligible for inclusion. The participants were assigned to continuous EFM or intermittent auscultation based on the flip of a coin. Both groups were followed during labor according to the most recent ACOG guidelines. However, fetal scalp blood pH and crossover from one group to the other were not used. RESULTS:A total of 1428 patients were included, 746 in the EFM group and 682 in the auscultation group. There were no differences between the groups in terms of maternal age, gravidity, parity, gestational age, and number of antepartum high-risk factors. More patients monitored electronically received oxytocin for either augmentation (52.4 versus 38.1%; P = .0001) or induction (15.6 versus 7%; P = .0001). The length of labor was longer in the EFM group (first stage 6.1 +/- 4.3 versus 5.5 +/- 3.7 hours; P = .006; second stage 29.4 +/- 18.6 versus 26.9 +/- 16.9 minutes; P = .01). There was a higher incidence of nonreassuring fetal heart rate patterns in the EFM group (23.4 versus 10.7%; P = .0001) and a higher rate of surgical intervention (11.2 versus 4.8%; P = .0001). This difference pertained to both vacuum extraction (5.8 versus 2.4%; P = .002) and cesarean delivery for suspected fetal distress (5.3 versus 2.3%; P = .005). There were no differences in 1- and 5-minute Apgar scores, fetal acidosis at birth, need for neonatal resuscitation, neonatal intensive care unit admission, use of assisted ventilation, neonatal hospital stay, or any other neonatal complications. Two neonatal deaths occurred in the EFM group and nine perinatal deaths in the auscultation group (two intrapartum and seven neonatal deaths). The perinatal mortality rates were 2.6 per 1000 and 13 per 1000 total births, respectively (P = .04). The two deaths in the EFM group and three of the neonatal deaths in the auscultation group may not have been prevented by intrapartum monitoring; however, four neonatal deaths from the auscultation group occurred in depressed (5-minute Apgar scores less than 7), acidotic (cord artery pH at or below 7.13) infants. The perinatal death rate related to fetal hypoxia was significantly less in the EFM group (zero of 746 versus six of 682; P = .03). CONCLUSION/CONCLUSIONS:In this controlled trial, intrapartum EFM, as the primary and only method of intrapartum fetal surveillance, was associated with decreased perinatal mortality due to fetal hypoxia but also with higher rates of surgical intervention for suspected fetal distress.