Faculty Bibliography

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: 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

OBJECTIVE: In an effort to elucidate possible causes of preterm labor, we undertook a prospective study of 50 patients consecutively admitted with intact membranes and preterm labor who eventually had a preterm delivery despite the use of tocolysis. STUDY DESIGN: A comprehensive evaluation plan was instituted. This included a detailed history and physical examination, targeted ultrasonography, amniocentesis for Gram stain, culture, and glucose determination, laboratory analysis for infection (complete blood cell count, urinalysis, and cervical and urine cultures) and for antiphospholipid antibody syndrome (antinuclear antibody, lupus anticoagulant, anticardiolipin antibody), pathologic examination of the placenta, and a urine toxicology screen. RESULTS: The following groups of possible causes of preterm labor were identified: (1) faulty placentation, 50% (25/50); (2) intrauterine infection 38% (19/50); (3) immunologic factors, 30% (15/50); (4) cervical incompetence, 16% (8/50); (5) uterine factors, 14% (7/50); (6) maternal factors 10% (5/50); (7) trauma and surgery, 8% (4/50); (8) fetal anomalies, 6% (3/50); and (9) idiopathic conditions, 4% (2/50). Among the 50 patients two or more possible causes were identified in 58% (29/50). CONCLUSION: We suggest that an exhaustive evaluation plan can identify possible causes in the majority (96%) of cases of 'idiopathic' preterm labor that result in preterm delivery

OBJECTIVES/OBJECTIVE:Transverse cerebellar diameter measurements have been established for singleton but not twin pregnancies. In singleton pregnancies controversy exists on whether cerebellar growth is affected by intrauterine growth retardation. We undertook this retrospective study in twin pregnancies to establish a nomogram for the transverse cerebellar diameter in twins and to assess the effect of growth retardation on this measurement. STUDY DESIGN/METHODS:A retrospective review was performed on 171 patients with twin pregnancies with reliable dating from 15 to 36 weeks' gestation who had been referred to our antenatal evaluation unit for routine ultrasonographic examination. Of the 342 fetuses, 322 were available for analysis and establishment of a nomogram for the transverse cerebellar diameter. Twenty-four twin, growth-retarded fetuses were analyzed separately. RESULTS:The transverse cerebellar diameter increased linearly with gestational age (r = 0.94, p < 0.001). Fifteen (63%) of the growth-retarded fetuses had a transverse cerebellar diameter of < or = 5th percentile for gestational age. CONCLUSION/CONCLUSIONS:We suggest that intrauterine growth retardation may affect cerebellar growth in twins.

The perinatal mortality rate of twins is four to 11 times higher than that of singletons, and twins are widely reported to have more morbidity than singletons, mainly because of a higher preterm birth rate. However, it is not clear that live-born preterm birth rate. However, it is not clear that live-born preterm twins suffer greater morbidity than comparable singletons. In fact, twins have been reported to develop pulmonary maturity earlier than singletons, which might result in decreased morbidity relative to comparable preterm singletons. We conducted this retrospective review of 496 consecutive singleton and 104 twin infants weighing 500-1499 g and born alive at 24-31 weeks' gestation to determine whether pre-discharge survival and morbidity in very low birth weight (VLBW) twin infants were greater than those of comparable singletons. The mean (+/- standard deviation) gestational age of the singletons was 27.5 +/- 2.0 weeks and of the twins 27.6 +/- 2.0 weeks. There were no differences in mean gestational age, gestational age distribution, mean birth weight, birth weight distribution, gender, or maternal race between the two groups. The pre-discharge survival rate for twins (77%) was not significantly different than that of singletons (82%). There were no differences between twins and singletons in the incidences of neonatal respiratory distress syndrome (63 versus 71%), pulmonary interstitial emphysema (14 versus 16%), patent ductus arteriosus (28 versus 29%), necrotizing enterocolitis (3 versus 5%), intraventricular hemorrhage (11 versus 16%), and retinopathy of prematurity (11 versus 18%). The incidence of bronchopulmonary dysplasia was significantly less in twins (27 versus 46%; P = .001).(ABSTRACT TRUNCATED AT 250 WORDS)

One hundred fifty-eight cases are reported of fetal cardiocentesis during the second trimester for the prenatal diagnosis of hemoglobinopathies. In all cases, fetal blood sampling by funipuncture was technically impossible or unsuccessful. There were nine fetal deaths possibly related to the procedure, for a total fetal loss rate of 6.5%. If one fetal loss that occurred 46 days after the procedure is excluded, the total procedure-related fetal loss rate is 5.6%. No cases of maternal chorioamnionitis, fetal cardiac trauma, or hemopericardium were encountered among the living infants. We conclude that cardiocentesis should be offered in highly selective cases when funipuncture is not technically feasible. In experienced hands, the procedure has a fetal loss rate of 6.5% with no morbidity among the survivors.

In summarizing the published data on the use of amniocentesis and fetal biophysical assessment in managing patients with PROM the following conclusions may be drawn: 1. Both amniocentesis and fetal biophysical assessment are reasonably good methods to predict the fetus who is doing well and could therefore safely remain in utero, as well as the fetus who is at high risk for developing sepsis and therefore in need of delivery. 2. Consideration of routine transabdominal amniocentesis for Gram stain and cultures in patients with PROM is reasonable. Measurements of glucose levels, esterase activity, or cytokines are only investigational, and their use in patient management cannot be advocated at this time. 3. Although there are no prospective controlled randomized trials to prove improved pregnancy outcome by the use of either amniocentesis or frequent biophysical assessment, nonrandomized comparative trials as well as trials using historic controls suggest that the use of either or both techniques in combination may be beneficial in managing PROM.

Varicella infection in the first trimester has been associated with a constellation of congenital abnormalities. The incidence of the congenital varicella syndrome is unknown, although it has been reported to be as high as 9%. In a prospective study performed between 1986-1990, 40 patients were identified who had first-trimester varicella infection. Pregnant patients were referred from physicians in the perinatal regional network after developing the classical picture of varicella infection. Targeted fetal ultrasound examinations were performed between 16-20 weeks' gestation in all cases and neonatal outcome was determined. Of the 40 patients, three had first-trimester losses and another underwent an elective termination of pregnancy after counseling. Of the remaining 36 women, one had fetal omphalocele. Thirty-five pregnancies continued until term, and no infant had features of the congenital varicella syndrome at birth. Other than the case of omphalocele, no major congenital anomalies were identified. This study, the largest series of patients with first-trimester varicella infection, showed an incidence of congenital varicella syndrome of 0% and an incidence of congenital anomalies of 3% (range 0-8% at 95% confidence level).