Gestational psittacosis: case report and literature review

In Europe, Chlamydia psittaci is a relatively common cause of abortion in sheep and other mammals. Psittacosis in humans is typically described as a mild-to-moderate flu-like illness. If psittacosis is acquired during pregnancy, it can present as a severe, progressive, febrile illness, with headache, disseminated intravascular coagulation, abnormal liver enzyme studies, and impaired renal function. Only cases with significant fetomaternal morbidity and mortality have been reported. Recovery from this disease follows termination of pregnancy and appropriate antibiotic therapy. Direct exposure of gravid humans to infected products of conception is the most commonly reported mode of transmission. Diagnosis is suggested by the placental histopathologic findings, which consist of an intense, acute intervillositis, perivillous fibrin deposition with villous necrosis, and large irregular basophilic intracytoplasmic inclusions within the syncytiotrophoblast. Commercially available genus-specific monoclonal antichlamydial antibody is available for the rapid confirmation of the diagnosis. In the United States, only two cases of gestational psittacosis have been previously reported. In contrast to the experience in Europe, both cases were associated with psittacine birds. This is the first reported instance of ovine-related gestational psittacosis documented in the United States. Gravid patients should be warned to avoid contact with sheep and their products, particularly during the spring lambing period.

Maternal melanoma metastatic to the placenta: a case report and review of the literature

Metastases of maternal cancer to the placenta and fetus are rare in cases of maternal primary malignancy. This report describes a case of malignant melanoma metastatic to the placenta, reviews the literature, and discusses the clinical significance. A 33-year-old woman presented at 30 weeks' gestation with multiple metastases from a malignant melanoma diagnosed 4 years previously. Rapid maternal deterioration necessitated premature cesarean delivery, and maternal death occurred 7 days later. The placenta showed multiple metastases of malignant melanoma. The infant, however, is alive and well at 7 months of age. Melanoma in pregnancy rarely results in metastasis to the conceptus, but when it does occur there may be fatal consequences to the fetus. Therefore, the placenta should be thoroughly examined for metastasis, which, if present, should alert the clinician to monitor the infant for development of malignant disease.

Embolism of fetal brain tissue to the lungs and the placenta

We describe a case of a 19-year-old G1P0 woman with an unremarkable prenatal course who presented at term in labor. Fetal bradycardia developed and forceps were used to deliver a male infant, who was born with Apgar scores of 0 and 0 and could not be resuscitated. Examination at autopsy revealed no gross evidence of trauma, but on microscopic examination of the lungs and the placenta, multiple fetal vessels contained emboli consisting of fragments of fetal cerebellar cortex. Previously reported cases of this rare phenomenon are reviewed and the pathogenesis is discussed.

Absence of the lateral philtral ridges: a clue to the structural basis of the philtrum

This study compares philtral development in the normal fetus with philtral development in specimens lacking normal philtral landmarks. Distinct differences in the structure of the upper lip were discovered between the two groups using a histological comparison. A new mechanism for the structural basis of the philtrum is proposed on the basis of these differences.

Complete hydatidiform mole with a coexistent embryo

We describe a case of a complete hydatidiform mole with a coexistent embryo. A 19-year-old Hispanic woman presented with an intrauterine pregnancy at 7 weeks gestational age. An ultrasound evaluation at that time showed a gestational sac and fetal heart activity was observed. Four weeks later, subsequent ultrasound study revealed no evidence of an embryo, and a pattern consistent with a hydatidiform mole. Dilation and curettage was subsequently performed that showed a classic hydatidiform mole on histological examination. Chromosome analysis revealed a normal 46,XX karyotype. DNA was extracted from the placental tissue, as well as maternal and paternal blood. Molecular genetic analysis was; performed with four variable number of tandem repeats (VNTR) probes and showed the placental tissue to consist of only paternal DNA with two genomic copies of each allele studied. These findings are consistent with the diagnosis of complete hydatidiform mole and its origin from an empty ovum fertilized by a single sperm. This is the first reported case of a living embryo coexistent with a complete hydatidiform mole documented by genetic analysis.

The biology of the twinning process: how placentation influences outcome

Placentation of twins has important bearing on the fetal development and neonatal outcome. Because of limitation in space of the endometrial cavity, twin placentas frequently collide during their expansion. This may restrict their growth and also lead to a somewhat increased rate of placenta previa. Moreover, abnormal cord insertions such as marginal and velamentous cords are much more frequent in multiple gestation. Absence of one umbilical artery is also much more frequent in twins. The best prognosis is had when two independent placentas develop, the dichorionic separate organs. Fusion of two separate placentas does not lead to vascular anastomoses in human twins, whereas it often does in other species (marmoset, cattle). Blood vessel fusion occurs only in monochorionic twins, all of which are "identical" (monozygotic). Large anastomoses (usually artery-to-artery) allow blood to shift rapidly from one to the other. Thus, when one twins dies, the survivor may quickly exsanguinate into the dead twin, leading to hypotension and occasionally to cerebral palsy. Arteriovenous anastomoses are the basis for the twin transfusion syndrome. This results in severe prematurity and gross discordance of all sorts of physical parameters. Knowing this type of vascular shunts helped develop the prenatal laser obliteration with salvage of the twins. The worst prognosis occurs with the rarest type of placentation in twin, in which both reside in the same cavity. This is the monoamnionic-monochorionic twin placentation. By moving about, the twins often entangle their umbilical cords and some 40% to 50% may die in utero.

Observations on neonatal mortality of the Chacoan peccary, Catagonus wagneri

The considerable neonatal mortality of a captive population of Chacoan peccaries, the taguá (Catagonus wagneri), in Paraguay was investigated with the examination of six newborn animals and one adult. Most deaths occur primarily because of restriction of space resulting in competition for space and nutrition. The adult had nonlethal inhalation pulmonary anthracosis. Neonatal pulmonary nocardiosis was noted in one infant and is believed to be related to the dust storms prevailing locally. Another neonate had a duplication of the pelvis, rear extremities, and one ovary, representing a type of conjoined twin classified as ischiopagus.

Strategies of ovarian function of importance to gynecologic investigations

OBJECTIVE

The purpose of this article was to examine the similarities and differences in ovarian morphology and function that are known to exist among mammalian species. The previous difficulties and present solutions to the characterization of ovarian function in non-domestic or non-laboratory species are discussed.

METHODS

The current literature regarding comparative ovarian structure and function was reviewed to identify examples of the diversity found with mammals.

RESULTS

Major differences in ovarian anatomy include location in the body cavity; the degree of membranous covering surrounding the ovary; vascularization of the ovary, oviduct, and uterus; and the organization of different cell types within the ovary. The differences in ovarian function are simplified in this review by categorizing the known examples into six groups according to patterns in follicle growth and development, mechanisms of ovulation, response of steroid target cells, and luteal function.

CONCLUSIONS

Each mammalian species has a unique expression of its ovarian function. The differences between species range from quantitative differences in ovarian cycle phase length to qualitative differences in cell type, endocrine activity, and mechanism of ovulation. These differences present a special problem to research scientists when they attempt to select models for studying many aspects of female reproduction.

Placenta pathology questions to the perinatologist

There are many reasons to advocate a routine screening for placental lesions. A quick study of the surfaces of the freshly delivered organ gives much relevant information. In certain circumstances the organ should be studied histologically, so as to have a permanent record of the pathologic findings, and also to advance our knowledge of some features that we have as yet no answers to. This communication addresses three pathologic findings at placental examination: meconium staining, presence of nucleated red blood cells, and chorangiosis. In all of these lesions, additional data need to be collected with the help of perinatologists so that the pathologic features can be better understood. It is especially desirable that better time frames for the meconium injury and the secretion of nucleated red blood cells be known.

Obstetrically important lesions of the umbilical cord

Many pathologic features of the umbilical cord affect fetal well-being adversely. Excessively long or short umbilical cords may be the cause of hematomas and thrombosis of cord vessels and the placental surface, thus causing fetal death and/or thrombocytopenia. In other cases, fetal hypoxia and central nervous system damage are possible outcomes. Thrombosis is also frequently induced by velamentous insertion of the cord, as are hemorrhages when the membranous vessels rupture during parturition. Entangling and knotting of the cord, especially of excessively long cords, may lead to similar lesions and fetal death. It was recognized recently that prolonged meconium exposure to the surface of the cord can cause partial necrosis of umbilical vessels and cord ulceration. The noxious moiety of meconium also causes contraction of the umbilical vessels, leading to fetal hypoperfusion and hypoxia. A stricture at the fetal end of the cord and excessive spiralling of a very long umbilical cord are often present in cases of unexplained fetal demise, especially in early pregnancy. Less common abnormalities are obstruction of the circulation by amnionic bands and varices.

Immunocytochemical localization of nonluteal ovarian relaxin

Relaxin has been demonstrated to be produced by the corpus luteum of the menstrual cycle and pregnancy and is also produced by the endometrium and decidua, although these nonluteal sources may not contribute to circulating relaxin concentrations. The reports of luteal production of relaxin have failed to consider nonluteal ovarian sources. To look for sources of nonluteal ovarian relaxin, human ovaries were collected from patients who underwent removal of the ovary for a variety of reasons. Tissues were fixed in formalin and embedded in paraffin. Two monoclonal antibodies were used for immunocytochemical staining, one directed against human relaxin and the other against the C peptide of prorelaxin. In addition to the expected staining of corpora lutea, the luteinized theca interna but not granulosa of developing follicles from ovaries with an active corpus luteum of the cycle also stained positive for both relaxin and prorelaxin. Ovaries from term pregnant women with luteinized theca also demonstrated staining for relaxin and prorelaxin. In addition to luteal and thecal cell staining, small clusters of pseudodecidual cells in the periphery of the ovary stained positive for relaxin and prorelaxin. These data indicate that the ovary contains theca interna-derived structural elements in addition to the corpus luteum that produce relaxin when a corpus luteum is active, while granulosa-derived elements do not. This suggests that luteal production of relaxin is from theca-derived elements and may explain instances of independent relaxin and progesterone secretion.

Cytokine expression in the placenta. The role of interleukin 1 and interleukin 1 receptor antagonist expression in chorioamnionitis and parturition

Interleukin 1 (IL-1) is known to be present in placental tissue and is implicated as an endogenous mediator of inflammation and parturition. This study was undertaken to assess the role of IL-1 receptor antagonist (IL-1ra) in the placenta. Placentas with acute chorioamnionitis, with meconium staining, and without significant inflammation were examined for immunohistochemical expression of IL-1 and IL-1ra. Interleukin 1 and IL-1ra immunoreactivity was variably noted in the amnion, trophoblast, vascular smooth muscle, stromal cells, fibrinoid, and decidua in all placentas. Interleukin 1 immunoreactivity was less intense than IL-1ra immunoreactivity, and both were generally more intense in acute chorioamnionitis. Interleukin 1 receptor antagonist was detected (approximately 5 to 6 ng/mL) in the amniotic fluid of pregnant women at term. Colocalization of IL-1 and IL-1ra in normal and inflamed placentas suggests that the balance between these proinflammatory and anti-inflammatory mediators plays a role in parturition as well as in the pathogenesis of acute inflammation. An increase and/or imbalance in the IL-1 and IL-1ra expression associated with chorioamnionitis may precipitate preterm labor.

Extension of the cleft lip phenotype: the subepithelial cleft

We present a previously undescribed occult malformation of the upper lip manifest by discontinuity of the orbicularis oris muscle. The relationship of this defect to our current concept of abnormal maxillary process development is discussed along with a proposal to extend the cleft lip phenotype.

Intrauterine death of a twin: mechanisms, implications for surviving twin, and placental pathology

In multiple gestations, intrauterine death of one fetus occurs frequently. Sonographic studies indicate that many twin pregnancies are converted in early pregnancy to singletons. The "vanished" twin is sometimes recognized as a fetus papyraceous (compressus) incorporated into the placenta of the survivor. Death of one twin later in pregnancy may have serious implications for the survivor, especially in cases of monochorionic twins. One postulated mechanism has been that thromboplastic proteins from the dead twin are transfused into the survivor's circulation, resulting in disseminated intravascular coagulation. More recently it has been proposed that massive blood loss may occur from the survivor into the more relaxed circulation of a dead monochorionic twin through vascular anastomoses. These mechanisms may explain the higher frequency of cerebral palsy in monochorionic twins. These concepts emphasize the importance of careful examination and thoughtful interpretation of twin placentas.

Physical and behavioral findings in a pseudohermaphrodite American bison

A pseudohermaphrodite American bison (Bison bison) behaved like an adult male when interacting with adult females, but like an adult female when interacting with adult males. Its chromosomes were a normal 60, XX and it had a uterus; but it had bilateral testes rather than ovaries. Skull measurements were intermediate between a bull and a cow. Gonadotrophin levels were typical of ovariectomized domestic cows or steers.

Maternal floor infarction: relationship to X cells, major basic protein, and adverse perinatal outcome

OBJECTIVE

Maternal floor infarction of the placenta is characterized by gross placental abnormalities and histologic evidence of X-cell proliferation. Previously, pregnancy-associated major basic protein has been localized to the placental X cell and identified at elevated levels in serum and amniotic fluid in all normal pregnancies. Here we test the hypothesis that pregnancy-associated major basic protein is localized to the X cells in maternal floor infarction and that it contributes to the pathophysiologic features of pregnancies complicated by maternal floor infarction.

STUDY DESIGN

Seven patients with eight pregnancies complicated by maternal floor infarction were evaluated. We analyzed placental tissue, serum, amniotic fluid, and placental cyst fluid for pregnancy-associated major basic protein.

RESULTS

Placental tissue from pregnancies complicated by maternal floor infarction had increased numbers of X cells and fibrinoid material that occupied or surrounded degenerating villi and that stained intensely for pregnancy-associated major basic protein. Serum pregnancy-associated major basic protein levels were variable and likely cannot be used to predict the occurrence of maternal floor infarction.

CONCLUSION

Pregnancy-associated major basic protein, a potent cytotoxin, is localized to X cells and is deposited in close proximity to chorionic villi in maternal floor infarction and may contribute to the pathophysiology of this disorder.

Effect of ACE inhibition on the fetal kidney: decreased renal blood flow

The kidneys of nine fetuses whose mothers were chronically hypertensive were examined microscopically. Three of these mothers used antihypertensive agents throughout pregnancy including one who used an angiotensin-converting enzyme (ACE) inhibitor. The tubular defects found in these kidneys were compared to the kidneys of 20 normal controls, 13 fetuses with various multiple malformation syndromes and six cases of the twin to twin transfusion syndrome. Evidence from these cases as well as the literature suggest that the primary mechanism by which ACE inhibitors affect development of the fetal kidney is through decreased renal blood flow.

Postnatal white matter necrosis in preterm infants

One hundred twenty-seven infants less than 36 weeks of gestation (mean +/- SE = 31 +/- 3.2 weeks) were studied with echoencephalography to determine the incidence and complications associated with white matter necrosis. Ten infants (8%) developed cysts ten or more days after birth, indicating postnatal onset of white matter necrosis. Univariate analysis showed that postnatal white matter necrosis was significantly associated with maternal infection (other than urinary infection), respiratory distress syndrome, and longer requirement of an oxygen concentration greater than 40%. Forward logistic regression analysis showed postnatal white matter necrosis to be associated with maternal infection, chronic placental infarction, congenital pneumonia, and longer requirement of an oxygen concentration greater than 40%. Neurodevelopmental outcome was abnormal during infancy in 4 of the 6 survivors with postnatal white matter necrosis. Severe respiratory disease and maternal and/or fetal infection appear to increase the risk of the immature brain to white matter necrosis, predisposing the infants to subsequent neurodevelopmental delay.

Intrauterine death in multiple gestation

Intrauterine death of one fetus in a multiple gestation is associated with significant morbidity and mortality in the surviving infant. This study is a retrospective review of 38 twin and 3 triplet gestations involving the intrauterine death of at least one fetus. The obstetrical history, placental pathology, autopsy findings, and neonatal history of the surviving infant are reviewed. Three cases involved the recent stillbirth of both twins, the remaining cases involved a surviving infant. In one case, neonatal death of a surviving twin occurred on day 19. In two sets of triplets, two stillbirths occurred, in the third case two infants were liveborn. The incidence of preterm delivery was 34%, which decreased to 18% if fetal cotwin death had occurred before 20 weeks gestation. Cesarean section was the method of delivery in 16 cases. There was an excess of velamentous cord insertions, which was most pronounced in the stillborn twin. Monochorionic placentation was found in 72%, also an excess. Neurological damage was known to have occurred in 19 of the 39 surviving infants. Fifteen of these 19 (79%) were associated with monochorionic placentation. The neurologically damaged twin infants, when compared to the normal infants, had the cotwin die later in gestation (31 vs 16.5 weeks), had a shorter duration between the death of the cotwin and delivery (2.5 vs 21 weeks), and delivered earlier in gestation (36.5 vs 39.5 weeks). The probable cause of neurological damage, in our opinion, was either exsanguination into the dead twin fetus, or disseminated intravascular coagulation which occurred in at least 13 cases. The incidence of antepartum death in a multiple gestation, and the potential for neurological damage is probably higher than previously thought. A review of the literature is presented and the clinical implications of this phenomenon are discussed.

Morbidity associated with prenatal disruption of the dividing membrane in twin gestations

We report eight cases of intrauterine rupture of the dividing membranes in diamniotic twin gestations and the resulting perinatal morbidity and mortality. The poor outcomes associated with these intrauterine amniotic ruptures included fetal and neonatal death secondary to cord entanglement, preterm rupture of the membranes, preterm labor and delivery, and amniotic band syndrome. The overall perinatal mortality rate was 44% (seven of 16), and the mean gestational age at delivery was 29 weeks (range 22-34). Possible etiologies for this intrauterine diamniotic rupture include fetal trauma to the dividing membranes, amniocentesis, infection, and developmental disturbances. A new theory is examined to explain the surviving twin's morbidity associated with intrauterine death of the co-twin. This study suggests that intrauterine rupture of diamniotic twin membranes carries a perinatal mortality consistent with that of true monoamniotic gestations and that, in fact, this entity may be more common than previously thought. Finally, a suspected monoamniotic gestation cannot be ruled out by the historic presence of a dividing membrane on previous ultrasound examination.