Orofaciodigital syndrome Type IV (Mohr-Majewski): early prenatal diagnosis in siblings

We report the sonographic and autopsy findings in two sibling fetuses with autosomal recessive orofaciodigital syndrome (OFDS) Type IV (Mohr-Majewski) diagnosed at 11-13 weeks' gestation. The first-trimester anomaly scan showed a markedly increased nuchal translucency (NT) thickness in both fetuses (4.7 mm and 5.1 mm). Both fetuses had multiple anomalies involving the brain, cranium, heart and skeletal system and their karyotypes were normal. The pregnancies were terminated and the autopsies showed findings consistent with Mohr-Majewski syndrome. These cases show the overlap between OFDS Type II (Mohr) and lethal short-rib-polydactyly syndrome Type II (Majewski) and confirm both the autosomal recessive inheritance of the condition and our ability to diagnose it early in pregnancy using detailed fetal ultrasonography.

Criss-cross heart: report of three cases with double-inlet ventricles diagnosed in utero

Criss-cross heart is a rare congenital cardiac anomaly characterized by crossing of the inflow streams of the two ventricles, due to an apparent twisting of the heart about its long axis and when the axes of the openings of the atrioventricular (AV) valves are not parallel. If unrecognized, this leads to incorrect sequential segmental analysis. We report three cases of double-inlet ventricle with a criss-cross spatial relationship of the AV valves detected on prenatal ultrasound examination at 19-23 weeks' gestation. The sequential diagnosis was confirmed at postmortem examination in two cases and by neonatal echocardiography in the other. Antenatal diagnosis of criss-cross effect of the AV valves is feasible, allowing correct fetal diagnosis and appropriate counseling for this rare form of congenital cardiac disease.

Ein fetaler zystischer Tumor im Ultraschallbild

Using ultrasonography we were able to identify prenatally an intrauterine cystic tumour next to a foetus at 22 weeks of gestation, which was later diagnosed as a cystic lymphangioma of the foetal neck.

Unusual histologic finding in tissue obtained from voluntary pregnancy termination: a case report

BACKGROUND

An unusual histologic finding in tissue obtained from voluntary pregnancy termination (VPT) is reported to demonstrate the utility of pathologic examination of this specimen.

METHODS

A 30-year-old woman with a history of depression was referred to the gynecology clinic for VPT in the eighth week of gestation. Material obtained from uterine cavity curettage was macroscopically and histologically examined. Based on the histological findings, a molecular study by polymerase chain reaction amplification (PCR) was performed to evaluate the presence of human papilloma virus (HPV) DNA. For DNA extraction, 4-microm-thick histological sections were stained with hematoxylin and examined under a stereomicroscope. The PCR amplification was performed with the L1 consensus primers Gp5+/Gp6+, giving an expected PCR product size of 150 bp: these primers have been developed to allow the detection of a broad spectrum of mucosotropic HPV genotypes.

RESULTS

Histological examination of tissue obtained from the VPT showed immature villi with post-abortive hydropic degeneration and the presence of a small fragment of cervical mucosa with a squamous intraepithelial lesion characterized by mild to moderate nuclear atypia (SIL). PCR revealed that this lesion was related to HPV. Subsequently, the pap smear and cervical biopsy revealed a high-risk squamous intraepithelial lesion due to high-risk HPV.

CONCLUSIONS

This report demonstrates that tissue obtained from VPT cannot be considered normal "a priori" and that a histological study can be useful to provide new information regarding a woman's gynecological health.

Spontaneous perforation of choledochal cyst and hyperemesis gravidarum

A 28-year-old primigravida at seven weeks gestation presented to the Accident & Emergency Department complaining of vomiting for five days. She was admitted and managed as a case of hyperemesis gravidarum. Two days later she developed abdominal distension. Ultrasound scan revealed ascites and common bile duct dilatation. The ascitic fluid was bile stained. At emergency laparotomy spontaneous perforation of the supraduodenal part of the common bile duct was seen. This was closed around a T-tube. She then underwent medical termination of pregnancy. The post-operative T-tube cholangiogram was suggestive of a type I choledochal cyst. Three months later this was excised and biliary enteric continuity restored by performing a hepaticojejunostomy. To the best of our knowledge, spontaneous rupture of a choledochal cyst in a patient of hyperemesis gravidarum has not been reported before. In this article, we discuss treatment options for choledochal cyst during pregnancy.

Congenital cystic adenomatoid lung malformation: report of two cases and literature review

Congenital cystic adenomatoid malformations of the fetal lung (CCAM) are rare embryonic developmental abnormalities. They are considered as benign hamartomatous or dysplastic lung tumors characterized by overgrowth of the terminal respiratory bronchioles at the expense of the saccular spaces. A minority of cases may not be identified by prenatal imaging techniques and the pulmonary lesions are recognized postnatally. Two cases of congenital cystic adenomatoid malformation of the fetal lung diagnosed in our institution during the last four years are reported. The ultrasonographic and pathologic findings of these cases are discussed.

Ultrasonographic prenatal diagnosis of isolated acephaly

First trimester obstetric ultrasonography of a 32-year old female patient revealed a 13-week-old (according to the length of the femur and abdominal circumference) intrauterine live pregnancy with the absence of the fetal head. Medical abortus was performed with the diagnosis of acephaly and final diagnosis was confirmed by pathological and radiological examinations. We present and discuss the possible etiopathologic mechanisms of an acephaly case, which is described as acardia-acephaly complex in the literature, and usually appears in cases of twin reversed arterial perfusion sequence, but has not been previously reported as an isolated finding.

Information for patients undergoing a prenatal diagnosis

OBJECTIVES

Lack of information is a frequent complaint with regard to physicians dealing with prenatal diagnosis (PD). The aim of the study was to find out how information on PD was perceived by patients and if they considered that they had been correctly informed by their physicians.

METHODS

We conducted a prospective study in Lariboisière Hospital (Paris) with 86 patients undergoing prenatal diagnosis between 2001 and 2003. A 23-item questionnaire was given to patients after delivery or termination of pregnancy (TP).

RESULTS

Fifty patients out of 86 answered the questionnaire. Twelve patients out of 50 underwent a TP. Information on foetal anomaly was insufficient for 11 patients out of 50 (22%). Some patients found the information too technical; others would like to see photos to illustrate the anomalies and the possible surgical repairs to be performed. Information was insufficient for one in four patients concerning maternal serum screening for Down's syndrome. Information before amniocentesis was considered sufficient by 9 out of 10 patients. Information on the risks of TP was not given or not understood by 10 out of 12 patients.

CONCLUSION

Information on prenatal diagnosis could be improved by using simple and accessible language, supported by written documents and photos for certain anomalies. More information should be given in cases of abstract anomalies and should be adapted to the social, ethnic and cultural background of the patient.

Association of HELLP syndrome with primary antiphospholipid syndrome--a case report

Authors present the first Hungarian case of a young pregnant woman with the association of antiphospholipid syndrome (APS) and hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome. After the onset of severe preeclampsia, the pregnancy was terminated but the patient's condition continued to worsen. New symptoms of APS, including deep vein thrombosis and ischemic nervus opticus lesion, developed in the patient followed by the onset of acute respiratory distress syndrome, which required respiratory therapy. Intensive treatment with plasmapheresis, high-dose intravenous immunoglobulin, high-dose corticosteroids, cyclophosphamide, and anticoagulants eventually led to full recovery. There have been only few scattered reports in the literature on the association of HELLP syndrome and APS, which was successfully managed with the combination of various immunosuppressive and immunomodulatory treatment modalities.

Genetically Identified Complete Hydatidiform Mole Coexisting with a Live Twin Fetus: Comparison with Conventional Diagnosis

Twin pregnancy consisting of a complete hydatidiform mole (CHM) along with a live co-existing fetus is a rare entity and difficult to diagnose. A 37-year-old Japanese woman demonstrated a living fetus, a placenta and a multicystic mass within one gestational sac on ultrasound at 10 weeks. Termination of the pregnancy was performed, and the specimen was classified as partial mole by macro- and microscopic findings. The karyotype of the molar tissue was 46XX. DNA polymorphism analysis demonstrated that fetal DNA showed bi-parental origin while molar DNA showed paternal origin only. Thus, this case was erroneously classified by ultrasonography, macroscopic and pathologic findings, then correctly diagnosed as a twin pregnancy with a CHM and co-existing normal twin fetus by DNA polymorphism analysis. Immunohistochemistry of p57(KIP2), the paternally imprinted and maternally expressed gene, supported the genetic diagnosis. This case suggested that conventional diagnostic methods were inadequate for accurate diagnosis of CHM with a co-existing fetus. DNA polymorphism analysis should be requested for the diagnosis of hydatidiform mole, especially in cases where it is difficult to discriminate between partial hydatidiform mole and CHM with a co-existing fetus.

Meeting health care needs of women experiencing complications of miscarriage and unsafe abortion: USAID's postabortion care program

Each year, an estimated 210 million women become pregnant. Worldwide, more than one fourth of these pregnancies will end in abortion or an unplanned birth. While many abortions may result from the desire to delay or avoid pregnancy, 15% to 20% of pregnancies will end in miscarriage or stillbirth with some causative agents being malaria, HIV/AIDS, and physical violence. Postabortion care (PAC) is needed to provide treatment for complications caused by incomplete or spontaneous abortion and critical family planning counseling and services to prevent future unplanned pregnancies that may result in repeat abortions. In 2003, the United States Agency for International Development (USAID) initiated a 5-year strategy wherein seven countries were provided financial funding and technical assistance. Since 2003, more than 3000 women have been seen in health centers and health posts for PAC services; more than 14,000 community members have received messages on unsafe abortion; family planning, and complications of unsafe abortion and miscarriage; and more than 600 documents were reviewed for inclusion in a global PAC resource package. This package has been used for developing Cambodia's national PAC policy and for developing patient education materials and provider job aids in Cambodia and Tanzania. These promising methodologies will be replicated in other countries.

Partial HELLP syndrome in pregnancy complicated by recurrent deep vein thromboses and palmar skin lesions in a patient with prothrombin gene 20210a mutation and antiphospholipid antibodies: an unusual case

A patient who developed thrombocytopenia and hypertension accompanied by high levels of antiphospholipid antibodies and abnormal liver function tests in the absence of a hemolytic anemia necessitating termination of pregnancy developed bilateral lower limb thromboses accompanied by painful maculo papular lesions on the palms of both hands a few days after ending the pregnancy. She was then also found to have a prothrombin gene G20210A mutation. She was treated with anticoagulation therapy, but her postpartum course was further complicated by pulmonary embolus. A Greenfield filter was inserted into the inferior vena cava. On low molecular weight heparin, her next pregnancy was uneventful and without any complications.

Coexisting ectopic and intrauterine pregnancies: a case report

BACKGROUND

The simulated presence of intrauterine and extrauterine pregnancies is a rare condition. Diagnosis is difficult, accomplished on grounds of strong suspicion (as in assisted reproductive treatment cases), on the presence of predisposing factors (pathology of salpinx) or as a coincidental finding in the emergency room when a patient presents after an elective or spontaneous abortion. An intrauterine pregnancy may be discovered in a patient who presents with ectopic pregnancy.

CASE

A 40-year-old multigravida was diagnosed with coexisting extrauterine and intrauterine pregnancies when she presented with a right ectopic pregnancy in the emergency room. The patient underwent partial right salpingectomy and an elective abortion.

CONCLUSION

Patients who present with acute pelvic pain must be investigated for coexisting ectopic pregnancy even though they have a proven intrauterine pregnancy. Such an investigation is even more important if the patient is undergoing assisted reproductive treatment. In patients who have had spontaneous or elective abortion, especially in cases of a gestation <4 weeks, the differential diagnosis should include coexisting ectopic pregnancy. Failure to diagnose this condition can have serious consequences.

Successful management of a consecutive cervical pregnancy by sonographically guided transvaginal local injection: case report and review of the literature

OBJECTIVE

The purpose of this study was to describe the successful management of a recurrent cervical pregnancy with local injection and to review similarly treated cases to determine adverse outcomes.

METHODS

A case of a recurrent cervical pregnancy treated with transvaginal local injection was reported. A MEDLINE English language search identified 90 cases of cervical pregnancy treated with local therapy. This literature was analyzed with regard to the various demographic and outcome variables described.

RESULTS

Successful use of the transvaginal local approach is described. A review of cases identified a mean maternal age of 33.6 years with a mean gestational age at diagnosis of 7.5 weeks. Bleeding was the most common presenting sign (79%). The mean beta-human chorionic gonadotropin level at the time of diagnosis was 27,798 IU with an average time to resolution of 7.5 weeks. The most common risk factor was a history of curettage (69%), followed by previous cesarean delivery (35%). An additional dose of methotrexate was needed in 6% of cases. Bleeding requiring alternate procedures was present in 5% of cases. There were no complications in 81% of cases. The need for transfusion and development of infection were seen in 3% of cases each. There was 1 case (1.1%) requiring hysterectomy, and no maternal deaths were reported.

CONCLUSIONS

Conservative management of cervical pregnancy using local injection has been reported to have a low complication rate and a high efficacy for cure.

A rare occurrence of trisomy 18 and trisomy 21 in a dizygotic twin pregnancy

OBJECTIVE

Case report of a rare combination of a trisomy 18 and 21 in a dizygotic twin pregnancy in a woman with a history of recurrent miscarriage, a neonatal death, no living offspring and Graves disease.

METHODS

Case report and literature search.

RESULTS

Only one other report in the literature of a combined trisomy 18 and 21 twin pregnancy was found.

CONCLUSION

The combination of a trisomy 18 and 21 in a dizygotic twin pregnancy is very rare. Despite the high frequency and clinical importance of aneuploidy, very little is known about the factors that may modulate meiotic non-disjunction.

Congenital lung malformations in the second trimester: prenatal ultrasound diagnosis and pathologic findings

PURPOSE

To correlate prenatal sonographic diagnosis of cystic lung malformations with fetopathologic findings after termination of pregnancy.

METHODS

We retrospectively analyzed the data of 16 terminated cases in which a cystic lung lesion was diagnosed pre- or postnatally.

RESULTS

On average, prenatal diagnosis was established on the 21(st) gestational week (range, 19-26 weeks). The cause of termination was severe polyhydramnios in 4 cases, nonimmune fetal hydrops in 4 cases, other congenital malformation in 5 cases (renal malformation, 2 cases; congenital diaphragmatic hernia, 3 cases), and obstetrical conditions (intrauterine death, placental abruption, spontaneous abortion) in 3 cases. In 11 cases, congenital cystic adenomatoid malformation (CCAM) was the presumptive prenatal diagnosis. Autopsy confirmed the prenatal diagnosis in 6 of them, while in the other 5 cases, an enteric cyst, a laryngeal atresia, an unidentified tumor, a pulmonary hypoplasia, and an extralobar pulmonary sequestration were found on histologic examination. On the other hand, the autopsy revealed CCAM in those 5 cases in which other malformations were suggested prenatally.

CONCLUSION

The prenatal sonographic diagnosis of CCAM is difficult. Our cases emphasize the important role of fetopathology even today in the verification of prenatal diagnosis based on sonographic examinations.

Complex conotruncal cardiac anomalies consecutively in three siblings from a consanguineous family possibly associated with maternal hyperhomocysteinemia

INTRODUCTION

Conotruncal defects represent an anatomically heterogeneous group of cardiac malformations affecting the outflow tract of the ventricles and the arterial pole of the heart. The exact etiology of congenital heart diseases is unknown.

CASE REPORT

A 31-year-old woman who had three offspring with complex conotruncal cardiac anomalies after consanguineous marriage was reported. The first child is still alive. However, the second affected child died at the age of 3 years. Fluorescence in situ hybridization studies of the siblings excluded CATCH(22) chromosomal abnormality. The maternal laboratory work-up was unremarkable except for low serum folic acid and cobalamin levels and high homocysteine levels. The woman received high dose pyridoxine, cobalamin and folate treatment preconceptionally, and she became pregnant. She delivered a healthy male infant without any abnormalities. Six months later, she became pregnant again without any preconceptional medications. When she was examined during the fourth pregnancy, unfortunately the fetus was found to have a restrictive ventricular septal defect, a right ventricle with two outflows and a right aortic arch. Her last pregnancy was terminated at 22 weeks. The 22-week-old female fetus was examined postmortem and the diagnosis of congenital heart disease was confirmed.

CONCLUSION

Cobalamin and folate administration may help to reduce the development of cardiac malformations.

Randomized comparison of second trimester pregnancy termination utilizing saline moistened or dry misoprostol

OBJECTIVE

The aim of this randomized prospective study was to compare efficacy and side effects of saline moistened misoprostol with dry misoprostol, administered 800 mug intravaginally every 6 h up to a maximum of 3 doses in 24 h for second trimester pregnancy termination.

MATERIALS AND METHODS

A total of 81 women seeking termination of second trimester pregnancy (55 fetal death, 17 fetal structural anomaly, 5 chromosomal abnormality, 4 other reasons) were randomly assigned to one of two treatment groups: (1) intravaginal non-moistened (dry) misoprostol in group A (n = 40) or (2) misoprostol moistened with 3 ml of saline in group B (n = 41).

RESULTS

All of the patients in either group aborted within 48 h (100% success rate). Delivery was achieved in a median (interquartile range) of 13 (40) h with the group A protocol and 12 (36) h with the group B protocol (P = 0.652). Delivery with first dose, delivery within 12 h and delivery within 24 h were similar (P > 0.05) in group B (34.1, 87.5 and 60%, respectively) and group A (25, 82.9, 46.3, respectively). Both treatment regimens were tolerable and with similar side effects.

CONCLUSION

Misoprostol moistened with saline was not more effective than dry misoprostol for second trimester pregnancy termination.

Brachytelephalangic chondrodysplasia punctata with severe spinal cord compression: report of four new cases

Brachytelephalangic chondrodysplasia punctata (CDPX1, OMIM: #302950) is a rare congenital skeletal dysplasia caused by arylsulfatase E deficiency (OMIM: #300180). Although the symptoms are usually mild, severe spinal cord compression by dysplastic vertebras may develop. We report four new cases with severe cervical spinal canal narrowing documented by radiography, magnetic resonance imaging (MRI), and autopsy. In all, nine cases of CDPX1 with severe cervical spinal cord compression have now been described. Because these cases account for a large proportion of all reported CDPX1 cases, we believe that an antenatal suspicion of CDPX1 should lead to genetic counseling and to investigations for spinal cord compression. After birth, this complication must be routinely anticipated, and we suggest spinal MRI in all CDPX1 infants. Unless spinal cord compression is confidently ruled out, we recommend that these newborns receive the same care as trauma patients suspected of craniocervical junction disruption.

Gastric carcinoma during pregnancy: report of a case

BACKGROUND/AIMS

Gastric cancer in pregnancy is extremely rare and often diagnosed at advanced stages. Well-recognized pregnancy-related symptoms, such as nausea and epigastric discomfort, can be the first symptoms of gastric cancer. Thus, the diagnosis of gastric cancer in pregnancy is difficult. We herein report a case of gastric cancer in pregnancy to alert clinicians to this rare possibility.

MATERIALS AND METHODS

A 22-year- old nulliparous woman was examined by a gynecologist with a complaint of low abdominal pain. An abdominal ultrasound of the patient revealed 7th week of gestation and also showed massive ascites. She was referred to a hospital for further evaluation. Her other symptoms included loss of appetite, early satiety, and postprandial fullness. Gastroscopy demonstrated a tumor originating from the cardia and invading throughout the distal corpus. The histopathological diagnosis was gastric carcinoma with signet ring cells and her pregnancy was terminated. An explorative laparotomy revealed an unresectable gastric cancer and multiple peritoneal implants. Tumoral invasion was detected in pancreas and spleen. She was admitted to the medical oncology clinic and received a palliative chemotherapy. Bilateral double-J-stent placement was performed because of obstructive uropathy. A nasogastric tube was inserted for intestinal decompression, and total parenteral nutrition was administered. An adequate pain medication was given. To date (3 months after the diagnosis) the patient has been well without any signs of progression.

CONCLUSION

Early diagnosis of gastric cancer is very important for a better outcome. The diagnosis may be delayed because mild gastrointestinal symptoms are common during pregnancy. Clinicians should take this into consideration in the differential diagnosis of persistent epigastric complaint during pregnancy. Suspicion and early upper gastrointestinal endoscopy are necessary.

Conservative management of second-trimester cervical ectopic pregnancy with placenta percreta

OBJECTIVE

To report successful conservative management of advanced cervical ectopic pregnancy with placenta percreta.

DESIGN

Case report.

SETTING

University tertiary care hospital.

PATIENT(S)

A 37-year-old woman with second-trimester cervical ectopic pregnancy and placenta percreta.

INTERVENTION(S)

Ultrasound-guided injection of potassium chloride into the fetal heart followed by multiple systemic methotrexate injections, removal of fetal bones, cervical cerclage suture, and Foley catheter placement for control of hemorrhage.

MAIN OUTCOME MEASURE(S)

Low maternal morbidity and successful conservative management with preservation of fertility.

RESULT(S)

The cervical ectopic pregnancy was treated successfully without significant morbidity; the uterus was preserved, and the woman was delivered of a full-term live fetus in the next pregnancy.

CONCLUSION(S)

Advanced cervical ectopic pregnancy with placenta percreta is associated with high morbidity with surgical intervention. Conservative management with attendant low morbidity and uterus preservation is possible in advanced cervical ectopic pregnancy.