Faculty Bibliography

We report the first attempt of reduction of monoamniotic twins, discordant for hypoplastic left heart syndrome, using a new fetoscopic technique. Employing sonographic guidance and endoscopic visualization, cord ligation was accomplished, but significant cord entanglement, not previously appreciated, resulted in the ligation of the umbilical cord of the normal fetus. Cord entanglement may frustrate endoscopic techniques in monoamniotic twins

OBJECTIVE: To determine whether the degree of cervical lengthening after cerclage and whether serial follow-up measurements of cervical length after cerclage are predictive of pregnancy outcome. METHODS: Eighty women whose primary physician determined that a prophylactic (n = 50) or urgent cerclage (n = 30) was indicated had transvaginal ultrasonographic evaluation before and after cerclage. Thereafter, most women had three additional transvaginal ultrasound examinations until 32 weeks' gestation. At each examination, the mean of three measurements was calculated. Statistical analyses were done by t test, analysis of variance, and logistic regression, with significance set at P <.05. RESULTS: The mean +/- standard deviation precerclage cervical length was 27.2 +/- 10.3 mm and after cerclage was 34.1 +/- 9.9 mm (n = 80, P <.001, paired t test). No significant association was found (r = -0.26) between the difference in cervical length (postcerclage - precerclage lengths) and pregnancy outcome. Patients with a prophylactic cerclage had a mean cervical length that was consistently longer in patients delivering at term compared with those who delivered preterm at 20 to 32 weeks' gestation. In the urgent cerclage group a significant difference in cervical length between those who delivered at term compared with preterm was evident only at 28 to 32 weeks. CONCLUSION: The increase in cervical length after cerclage is not predictive of term delivery. Serial cervical length measurements in the late second or early third trimester predict preterm birth but could provide earlier warning in patients with a prophylactic cerclage than in patients with urgent cerclage

We report only the 3rd case of closure of amniorrhexis following genetic amniocentesis. Our technique is the first to use endoscopic visualization of the rupture site and apply maternal platelets and fibrinogen/thrombin (Hemaseel Haemacure Corp Sarasota F1). The patient underwent repair at 20.6 weeks, 26 days after spontaneous rupture of membranes post-amniocentesis. At the time of the procedure the amniotic fluid index was 1 cm. Patient was delivered at 32.3 weeks secondary to complications of diabetes and severe preeclampsia. The neonate had APGARS of 7 at 1 min and 8 at 5 min and was discharged home on Day 21 of life

OBJECTIVE: To assess the risks and benefits to patients who carry to term after undergoing a Shirodkar cerclage where the cerclage is not removed until the patient presents in labor. METHODS: A retrospective analysis was conducted examining all patients who underwent a Shirodkar cerclage employing a 5 mm Mersilene band. All the cerclages were placed by a single operator over a twenty five year span, from 1/01/74 till 10/01/98. Only patients who delivered vaginally or were allowed a trial of labor were included. In all cases, the cerclage was removed under regional anesthesia after the patient presented to the hospital in labor. RESULTS: Ninety six cerclage procedures were performed over that period. Eighty two pregnancies qualified for review. Sixty two patients delivered vaginally (76%). Nine cesareans were indicated for failure to progress in labor (11%) with cervical dystocia possibly implicated in one. There were no cases of ruptured uteri or the development of uterine windows. Of the 82 pregnancies there were five cases (6%) of minor cervical laceration. CONCLUSION: Allowing patients to proceed to labor with a Shirodkar, cerclage in place, does not increase the risks of cervical dystocia, cervical laceration, or uterine rupture above the reported incidence for these complications in patients in whom the cerclage is removed prophylactically

OBJECTIVE: To determine changes in length of incompetent cervices after cerclage, using transvaginal ultrasound. METHODS: Patients were enrolled in a prospective, observational study under an Institutional Review Board-approved protocol. McDonald or Shirodkar sutures were placed according to physician preference. Pre- and postcerclage cervical lengths were measured within 72 hours of the procedure. At each examination, the first measurement was discarded, and a mean of the subsequent three measurements was calculated. RESULTS: Twenty-one Shirodkar and ten McDonald operations were done. The mean (+/- standard deviation) precerclage cervical length was 2.7+/-0.9 cm and the postcerclage cervical length was 3.6+/-0.9 cm (P<.001, paired t test). CONCLUSION: Prophylactic cerclage results in measurable increases in cervical length, which might contribute to the success of the procedure. Further study is needed to determine whether the degree of cervical lengthening after cerclage predicts term delivery

PURPOSE: To better understand radiation complications of arteriovenous malformation (AVM) radiosurgery and factors affecting their resolution. METHODS AND MATERIALS: AVM patients (102/1255) who developed neurological sequelae after radiosurgery were studied. The median AVM marginal dose (Dmin) was 19 Gy (range: 10-35). The median volume was 5.7 cc (range: 0.26-143). Median follow-up was 34 months (range: 9-140). RESULTS: Complications consisted of 80/102 patients with evidence of radiation injury to the brain parenchyma (7 also with cranial nerve deficits, 12 also with seizures, 5 with cyst formation), 12/102 patients with isolated cranial neuropathies, and 10/102 patients with only new or worsened seizures. Severity was classified as minimal in 39 patients, mild in 40, disabling in 21, and fatal in 2 patients. Symptoms resolved completely in 42 patients for an actuarial resolution rate of 54% +/- 7% at 3 years post-onset. Multivariate analysis identified significantly greater symptom resolution in patients with no prior history of hemorrhage (p = 0.01, 66% vs. 41%), and in patients with symptoms of minimal severity: headache or seizure as the only sequelae of radiosurgery (p < 0.0001, 88% vs. 34%). CONCLUSION: Late sequelae of radiosurgery manifest in varied ways. Further long-term studies of these problems are needed that take into account symptom severity and prior hemorrhage history.

We present a case of mid pregnancy loss with retained intrauterine contraceptive device associated with fetal Candida infection. Review of English literature identified 53 additional cases of fetal candidal infection, with 17 associated with an IUCD in situ. The presence of an IUCD was associated with delivery at a statistically significant earlier gestational age when compared to cases not associated with an IUCD (23.3 +/- 4.9 vs 31.6 +/- 7.0, p < 0.001). Seventy-seven percent of fetal candidal infections associated with an IUCD were systemic (heart, brain, liver, gastrointestinal, lung) compared to 33% of cases not associated with an IUCD. In contrast to bacterial intraamniotic infections there was a low incidence of maternal febrile morbidity. An hypothesis as to the pathogenesis of Candidal infections in the presence and absence of an IUCD is offered as well as a paradigm for the management of the gravid patient with an IUCD in situ