Uterine artery embolization--a successful treatment to control bleeding cervical pregnancy with a simultaneous intrauterine gestation

A case of a woman suffering from a bleeding heterotopic cervical pregnancy is described. The concurrent cervical pregnancy and intrauterine gestation were diagnosed by ultrasound and bleeding was initially controlled with selective fluoroscopic uterine artery embolization. A selective fetal reduction was done with ultrasound-guided intracardiac potassium chloride. Uterine artery embolization has been used successfully to control haemorrhage in cervical pregnancies when the main goal was to allow preservation of the uterus, thus maintaining potential fertility. This is the first report of arterial embolization used to control bleeding for maintaining a concurrent intrauterine heterotopic pregnancy in an in-vitro fertilization patient. Unfortunately, subsequent conservative measures led to undesired outcome. This procedure initially controlled the bleeding without disrupting the intrauterine fetal cardiac activity.

[Prenatal diagnosis. II. Importance of ultrasonographic markers in prenatal diagnosis of chromosome abnormalities]

The Medical Genetic Unit of the University of Zulia (MGUUZ) has developed a Prenatal Diagnosis Program (PDP) since January-1993, in which Genetic Risk Factors are determined in couples who request prenatal genetic counseling. In this program, different prenatal diagnostic procedures are performed to detect congenital defects during intrauterine life. One of these procedures is the Fetal Sonogram (FS). FS is a non invasive technique which permits the prenatal diagnosis of many genetic dysmorphic syndromes. Through the search of abnormal specific characteristics in the fetus, chromosomopathies may be suspected. These findings are named "Echosonographic Markers of Chromosomal Abnormalities" (EMCA). During three years (January-1993 to December-1996), patients attended in the PDP included 321 pregnant women in which 312 FS were performed. Abnormal outcomes were 22 (17 with isolated congenital malformations and 5 with EMCA). Only one fetus with chromosome abnormality (46,XX21q-) could not be detected by FS. The goals of this paper are: 1) to report 5 patients with sonographic markers suggestive of chromosomal abnormalities and 2) to show the FS usefulness in prenatal diagnosis of chromosompathies. We conclude that, in the search of the EMCA the FS should be offered systematically to all pregnant women without recognizable genetic risk. They are the main group with optimal reproductive age and in consequence, with the possibility of having a relatively major number of conception outcomes with congenital defects, with or without chromosomic etiology. The majority of those defects can be detected by FS and could allow us to select the patients in which the use of an invasive prenatal diagnostic procedure could be justified.

Intracranial calcification in Raine syndrome: radiological pathological correlation

We report the seventh known patient with Raine syndrome, a recently recognised, lethal sclerosing bone dysplasia associated with severe craniofacial dysmorphism and intracranial calcification in whom the CT findings are correlated with the gross and microscopic abnormalities found in the brain at autopsy.

Single intrauterine fetal death (fetus papyraceus) due to uterine trauma in a twin pregnancy

Fetus papyraceus is a rare condition. We describe the intrauterine fetal death with subsequent fetus papyraceus of one twin due to blunt maternal trauma in the second trimester of pregnancy. Blunt maternal trauma should raise the clinical suspicion of fetal death and dictate further observation; in a twin pregnancy, the possibility of a single fetal death should be investigated.

Arrhythmia in early pregnancy: a predictor of first-trimester pregnancy loss

OBJECTIVE

To determine the prognostic significance of cardiac arrhythmia detected in the first trimester.

DESIGN

Cases in which embryonic arrhythmia was detected by transvaginal ultrasound between 6 and 9 weeks of gestation were retrospectively identified and reviewed.

RESULTS

Embryonic arrhythmia was noted in four of 950 ultrasound examinations. There was associated ventricular bradycardia in three cases, one of which also had an atrial rate below the normal range for gestational age. No cardiac activity was detected at the follow-up examination 1 week later in three cases. In the other, the embryo was alive but there was severe growth delay and the scan the following week confirmed embryonic death.

CONCLUSION

This report suggests that arrhythmia in early pregnancy is associated with subsequent pregnancy loss.

Fetal blood sampling immediately before and within 24 hours of death in monochorionic twin pregnancies complicated by single intrauterine death

OBJECTIVE

Our goal was to investigate the mechanisms that play a role in intrauterine death in monochorionic twins and that contribute to the high perinatal mortality and morbidity in the survivors.

STUDY DESIGN

In 8 monochorionic twin pregnancies complicated by the intrauterine death of a single twin, we took samples from 5 twin fetuses immediately before death and from 4 of their cotwins and also from 4 surviving fetuses within 24 hours after death of the cotwin.

RESULTS

Four of the 5 fetuses sampled who subsequently died were acidemic and 3 were hypoxemic. None of these fetuses or their cotwins were anemic at that time. All 4 survivors sampled within 24 hours of the death of each cotwin had low hematocrits.

CONCLUSION

Fetal anemia, probably the consequence of acute blood loss just before the time of death of the cotwin, may play a role in the high mortality and morbidity found in the surviving twin. It is unlikely that immediate delivery of the surviving twin after death could affect the outcome.

[A rare etiology of abdominal calcifications: lithopedion]

We report a case of a rare and particular cause of abdominal calcifications represented by the lithopedion. We describe different radiologic appearances observed by: abdominal plain film, echography and CT. It appeared to us that abdominal plain film alone is sufficient for diagnosis and undertaking surgery. Echography and CT are helpful, especially for complementary evaluation.

Legal problems related to obstetrical ultrasound

Malpractice suits related to fetal anomalies are now the most common type of litigation involving ultrasound, surpassing ectopic pregnancy. Missing an anomaly on a sonogram performed for a standard indication, such as dating, is the most frequent type of litigation. Other causes of litigation include invented anomalies and unrecognized anomalies that are visible in retrospect on the ultrasonic images. Rarer causes of malpractice problems relate to failure to communicate the results of a sonogram in a timely fashion, failure to inform the patient of the findings about the sonogram at the time the patient is seen, and failure to perform ultrasound studies for anomalies when there is clinical indication to do so, such as elevated alpha-fetoprotein or polyhydramnios. The level of protection given by the obstetrical guidelines are discussed. Particular areas of concern relate to litigation involving missed fetal heart malformations, spina bifida, absent distal limbs, and twins.

A case of mid-trimester intrauterine fetal death with Cushing's syndrome

A 34-year-old woman was diagnosed with Cushing's syndrome after her first pregnancy ended in intrauterine fetal death at 25 weeks' gestation. She subsequently had a successful pregnancy after treatment of her disease. Although patients with Cushing's syndrome rarely conceive, abortion, preterm labor, and intrauterine growth retardation are common when they do.

Early pregnancy detection and the hormonal characterization of embryonic-fetal mortality in fallow deer (Dama dama)

The objectives of this investigation were to 1) determine serum concentrations of progesterone (P4), estrone sulfate (E1S) and pregnancy-specific protein B (PSPB) from estrus synchronization through mid-gestation in the fallow doe (Dama dama) and 2) characterize the hormonal profiles of does whose embryos or fetuses died in utero. Ten fallow does were synchronized for 14 d with an intravaginal P4-releasing device (CIDR) and were naturally mated after CIDR removal. Blood samples were collected at CIDR insertion, CIDR removal and at intervals through Day 203 post-CIDR removal for analysis of P4, E1S and PSPB by radioimmunoassay (RIA). Ultrasonography was performed on Days 49 and 69 post-CIDR removal. Serum P4 at the time of CIDR insertion was 4.8 +/- 0.6 ng/ml, and at CIDR withdrawal it was 6.2 +/- 0.3 ng/ml. Concentrations of E1S and PSPB were nondetectable at CIDR insertion. Serum E1S was highest at Day 93, and PSPB was first detectable in pregnant does at Days 27 to 30 post-CIDR withdrawal. Ultrasonography on Day 49 revealed that 6 does were pregnant, 2 were not pregnant and 2 others were diagnosed originally as early pregnant. At Day 69, ultrasonography revealed that 6 does (60%) were pregnant and 4 (40%) were not. A comparison of the ultrasonographic and hormonal data indicated that the 2 does diagnosed as early pregnant on Day 49 had conceived but had lost the pregnancy. A third doe which was pregnant on Day 69 lost the fetus later in gestation. Hormonal profiles of does whose embryo or fetus had died were characterized by erratic P4 and E1S profiles, with PSPB becoming undetectable in the 3 does by Days 49, 65 and 80 post-CIDR removal. These data 1) demonstrate the timing for the collection of serum samples for determining early pregnancy in fallow does using 3 hormonal methods and 2) characterize the hormonal profiles of 3 fallow does with embryonic-fetal loss.

[The spontaneous reduction of a twin pregnancy in two mares]

Twin pregnancies are a serious problem in stud medicine as they terminate in most cases in abortion, stillbirth or the delivery of dead or weak and deformed foals. In recent years, the introduction of sonography has greatly improved the management of mares with twin conceptuses, in particular monitoring the phenomenon of spontaneous embryo reduction to a single vesicle. This allows supervision of pregnancy with relatively little expenditure and loss of time. We document the spontaneous reduction to single vesicles of unilateral twin pregnancies in a draught- and a warmblood-mare. In both mares diagnosis of twins was made 17 days after covering; they probably resulted from synchronous double-ovulations. After another 5 days, distinct signs of the loss of one conceptus were recognized and, subsequently, only single pregnancies existed. No interventions were necessary.

Omphalocele with absent radial ray (ORR): a case with diploid-triploid mixoploidy

We observed omphalocele, absence of radii, hypoplasia of one humerus, a hemivertebra, and syndactyly in a stillborn male at 22 weeks of gestation. Craniofacial and genitourinary abnormalities were absent. DNA measurement by flow cytometry on a paraffin-embedded autopsy specimen showed 32% triploid cells. ORR (omphalocele-radial ray) complex appears to be a consistent combination, and diploid-triploid mixoploidy may be one of its causes.

Septic shock in pregnancy: a case report

We present the clinical course of a pregnant woman in septic shock. While we were managing this case, an elevated pulmonary capillary wedge pressure was found, expressing left ventricular dysfunction. Therefore we question the widely accepted and recommended practice of loading the pregnant women in septic shock with 1 to 2 L of crystalloids before the institution of central monitoring. It is our belief that an aggressive and earlier central monitoring of the hemodynamic status can result in better treatment decisions.

[Modern fetal autopsy oriented to clinical demands using technical information methods]

Modern ultrasonic diagnostic instruments with high resolution and color Doppler sonography allow the obstetrician to describe pathological findings very precisely and at an early stage of pregnancy. The use of high-resolution ultrasound makes it possible to detect heart malformations already between the 8th and 10th week of gestation. This development has essentially changed the clinical requirements on fetal autopsy which in its traditional way no longer meets the increased demands. Unless the pathologists faces this challenge the importance of fetal autopsy will diminish. Modern image databases and communication techniques allow the pathologist to have direct access to text and images of pre-findings by other clinics. Great importance, however, must be attached to the interdisciplinary cooperation with obstetricians and geneticists. We report on routine fetal autopsy by using an interdisciplinary database an the Charité.

Validation of radiographic criteria for the diagnosis of Down syndrome in stillborn infants

We assessed the utility of radiographic findings as aids to the diagnosis of Down syndrome (DS) in stillborn infants. The iliac index may help to confirm the diagnosis of DS in stillborn infants in whom it is suspected clinically, but in whom it cannot be confirmed cytogenetically. It also can serve as a screening procedure to select stillborns in whom fluorescent in situ hybridization of fixed tissues should be completed. An iliac index of 59 degrees differentiates between control and affected stillborns with the highest accuracy, but false positives persist above 55 degrees, and false negatives are common below 64 degrees. We recommend that a conservative cutoff value of 55 degrees be used if the radiographic data serve as the principal means of diagnosing DS in stillborn infants. A cutoff value of 64 degrees may be appropriate if the radiographic data are used to screen stillborn infants for fluorescent in situ hybridization studies.

Couvelaire uterus

Uteroplacental apoplexy is a rare but nonfatal complication of severe forms of placental abruption. It occurs when vascular damage within the placenta causes hemorrhaging that progresses to and infiltrates the wall of the uterus. It is a syndrome that can only be diagnosed by direct visualization or biopsy (or both). For this reason, its occurrence is perhaps underreported and underestimated in the literature. The subject of this report is a 24-year-old pregnant woman who had a placental abruption an in whom classic uteroplacental apoplexy was diagnosed at the time of her cesarean section.

Autopsy, radiographic, and prenatal ultrasonographic examination of a stillborn fetus with femoral facial syndrome

Femoral facial syndrome (FFS) is comprised of cleft palate, micrognathia, short or absent femora, and vertebral and genitourinary malformations. We report on a stillborn fetus with FFS delivered to a mother with gestational diabetes. Prenatal ultrasound examination showed abnormalities at 21 weeks of gestation; prior ultrasound findings were interpreted as normal. Long bone histology showed disorganization of the growth plate with a relative decrease in cartilaginous matrix and vacuolization and binucleation of the chondrocytes.

Reproductive efficiency in the common marmoset (Callithrix jacchus): a longitudinal study from ovulation to birth monitored by ultrasonography

This study examines reproductive efficiency in the common marmoset monkey, Callithrix jacchus, using sequential ultrasound examinations to establish ovulation number, implantation rate, and incidence of prenatal loss. Ultrasound was carried out with a 10 or 7.5 mHz probe in nonsedated animals, daily during the late follicular phase, approximately twice a week until day 20 after ovulation, and at days 35, 56, and 85 of pregnancy to enable visualization of gestation sacs, heartbeats, and fetal heads, respectively. Ovulatory follicles could be seen 3-4 days before ovulation and by day -2, 98% of ovulating follicles were > 2mm diameter, although almost 10% of follicles of this size disappeared without ovulating. Total number of ovulating follicles for 15 females was 45 (mean ovulation rate = 3.0, range 2-4). In the 14 animals that conceived, 41 corpora lutea were identified (mean ovulation rate = 2.9) within 10 days of ovulation. All pregnancies went to term (no abortion occurred) resulting in the birth of 37 neonates (9 triplets, 5 twins) and an average litter size of 2.64. All four losses were confined to the embryonic period (< day 85), two occurring before day 35, one between days 35 and 56, and one between days 56 and 85. In demonstrating that 90% of ovulatory follicles gave rise to live offspring, the results of this study indicate an extremely high reproductive efficiency in the marmoset monkey (when maintained under favorable captive conditions) and a rate of prenatal loss much lower than that reported for other primate species.

Pelvic ultrasound performed by emergency physicians for the detection of ectopic pregnancy in complicated first-trimester pregnancies

STUDY OBJECTIVE

To determine the accuracy and application of pelvic ultrasound performed by emergency physicians in detecting ectopic pregnancy (EP) in complicated first-trimester pregnancies.

METHODS

We studied consecutive pelvic ultrasounds performed in all women who presented with abdominal pain or vaginal bleeding during the first trimester of pregnancy over a 6-month period. Patients with clinical evidence of incomplete abortion were not included. We compared ultrasound results with subsequent ultrasound findings by the radiology department and correlated them with follow-up diagnoses and outcomes.

RESULTS

Of the 136 eligible patients, a final diagnosis was rendered in 125; 11 were lost to follow-up. These ED ultrasound findings were recorded: established intrauterine pregnancy (IUP) with embryonic structures, 87 (70%); indeterminate scan revealing no distinct evidence of IUP or EP, 15 (12%); early intrauterine gestational sac of less than 6 weeks without embryonic structures, 12 (10%); EP, 8 (6%); blighted ovum, 2 (2%); and molar pregnancy, 1 (1%). The initial ED ultrasound determination was consistent with radiology department findings, final outcome, or both in 121 (96%) (95% confidence interval [CI], 91% to 97%). ED ultrasound accurately identified 87 pregnancies with intrauterine embryonic structures, including 5 patients with fetal demise (95% Cl, 97% to 100%). Diagnosis of pregnancy location in these 87 patients effectively ruled out EP, with a negative predictive value of 100%. The sensitivity and specificity of ED ultrasound in the detection of EP were 90% and 88%, respectively.

CONCLUSION

Pelvic ultrasonography performed by emergency physicians can be used to rule out EP and make an accurate diagnosis in most patients with complicated first-trimester pregnancies during the initial ED visit. The remaining patients at risk can be identified and a diagnosis made by means of follow-up ultrasound and serial hCG determinations.

Fetal ultrasonography in maternal PKU

Maternal phenylketonuria (PKU) is teratogenic and results in birth defects that include microcephaly, mental retardation, congenital heart disease, and intrauterine growth retardation. Treatment with a low phenylalanine diet can prevent or reduce the severity of the complications. Optimal benefit, however, requires frequent monitoring with fetal ultrasonography as a critical element. We have studied ultrasonography in 39 pregnancies enrolled in the Maternal PKU Collaborative Study and followed at our centre. First-trimester examinations in 24 pregnancies resulted in the discovery of non-viability in five. In each, this led to discontinuation of the difficult and expensive diet. Among the 33 pregnancies with second-trimester evaluation, congenital heart disease was identified in five. Two of these pregnancies were terminated. Microcephaly as determined by biparietal diameter (BPD) was identified in the second trimester in only one of nine fetuses who had microcephaly at birth. Among 20 pregnancies with third-trimester ultrasound, fetal microcephaly was identified by BPD in three of seven who had birth microcephaly. We conclude that fetal ultrasonography in maternal PKU is valuable during the first trimester in identifying non-viable pregnancies and determining gestational age and is also valuable during the second trimester in identifying congenital heart disease and perhaps other major anomalies, but not in identifying fetal microcephaly. Third-trimester ultrasound seems to be of limited usefulness.

Qualitative analysis of fetal movement patterns in the Neu-Laxova syndrome

The Neu-Laxova syndrome was diagnosed in a fetus at 34 weeks' gestation on the basis of ultrasonographic qualitative analysis of fetal movement patterns and malformations. The first ultrasound study was performed at 34 weeks' gestation and a dead 960 g female fetus was delivered at 36 weeks' gestation.