Autoimmune polyglandular syndrome type 2 in pregnancy: a case report and review of the literature

Objectives

Autoimmune polyglandular syndromes are uncommon heterogeneous conditions characterized by the association of two or more organ-specific endocrinopathies. Very few cases of these syndromes have been described during pregnancy. Here we report a case of autoimmune polyglandular syndrome type-2 presenting during pregnancy and complicated by preeclampsia with severe features.

Case presentation

The patient is a 35-year-old G7P0242 woman with a history of adrenal insufficiency, type 1 diabetes mellitus, and chronic lymphocytic thyroiditis. She was admitted to our institution at 34 weeks’ gestation for preterm contractions, nausea, and lower extremity edema for a few weeks prior to admission. At 35 weeks’ gestation, she developed preeclampsia with severe features requiring repeat cesarean section with good maternal and fetal outcomes. Recognizing the occurrence of this rare syndrome during pregnancy, adequate replacement of the deficient hormones, and close maternal and fetal surveillance are essential to achieving favorable outcomes.

Conclusions

To our knowledge, this is the first reported case of a pregnant woman with autoimmune polyglandular syndrome type-2 complicated by preeclampsia with severe features.

Clinical Stratification of Pregnant COVID-19 Patients based on Severity: A Single Academic Center Experience

OBJECTIVE

This study aimed to describe baseline characteristics of a cohort of pregnant women infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and determine if these correlate with disease severity and perinatal outcomes.

STUDY DESIGN

This was a retrospective cohort trial conducted at the University of Texas Medical Branch Galveston, Texas. All pregnant women presented to our medical center, who were screened and tested positive for SARS-CoV-2 virus, were included. We stratified our study population in three groups: asymptomatic, symptomatic not requiring oxygen therapy, and patients requiring oxygen support to maintain oxygen saturation >94%. Relevant population characteristics, laboratory data, and maternal and neonatal outcomes were abstracted. A p-value <0.05 was considered statistically significant.

RESULTS

Between March and July 2020, 91 women tested positive for SARS-CoV-2 upon admission to our labor and delivery unit. Among these, 61.5% were asymptomatic, 34.1% were symptomatic, and 4.4% required oxygen support. Our population was mainly Hispanic (80.2%), multiparous (76.9%), obese (70.3%), and with a median age of 27 years. Median gestational age at symptom onset or diagnosis was 36 weeks. Significant differences were found between gestational age and disease severity. Maternal characteristics including age, body mass index (BMI), and presence of comorbid conditions did not appear to influence severity of SARS-CoV-2 infection. Significant laboratory findings associated with increasing disease severity included decreasing hemoglobin and white blood cell count, lymphopenia, and increasing levels of inflammatory markers including CRP, ferritin, and procalcitonin. Maternal and neonatal outcomes did not differ among groups. No SARS-CoV-2 was detected by polymerase chain reaction testing in neonates of mothers with COVID-19.

CONCLUSION

Pregnant patients with COVID-19 infection are predominantly asymptomatic. Patients appear to be at increased risk for more severe infection requiring oxygen support later in pregnancy.

KEY POINTS

· The majority of pregnant patients with COVID-19 are asymptomatic and <1 in 20 require oxygen support.. · Women in the later stages of pregnancy may be at increased risk for severe infection.. · Anemia, leukopenia, CRP, ferritin, and procalcitonin are associated with increasing severity..

Conservative Management and Planned Surgery for Periviable Advanced Extrauterine Abdominal Pregnancy with Favorable Outcome: Report of Two Cases

Advanced abdominal pregnancy is an extremely rare condition that poses diagnostic and management challenges. A high index of suspicion and careful assessment of the patient's symptoms, supplemented with obstetric ultrasound, and magnetic resonance imaging, are crucial for timely diagnosis and management to prevent life-threatening complications. The presence of periviable fetuses in advanced abdominal pregnancies increases the challenge to achieve a balance between maternal and fetal benefits and risks. Early diagnosis and management decisions via a multidisciplinary approach and planned delivery are of paramount importance to minimize complications and achieve favorable maternal and fetal outcomes. Even in the setting of oligohydramnios and suspected preterm premature rupture of membranes, in-patient conservative management and an individualized planned surgical approach that includes removing or leaving the placenta in place are appropriate for managing the periviable abdominal pregnancy.

Twin pregnancies discordant for single umbilical artery

OBJECTIVE

To evaluate the perinatal outcomes in twin pregnancies discordant for single umbilical artery (SUA).

STUDY DESIGN

This was a retrospective cohort study. Our database was searched for all cases of twin gestation and SUA from 1997-2009. We reviewed all the maternal and neonatal records and placental pathology reports. The outcomes of the SUA fetuses were compared to that of their co-twins with a 3-vessel cord (3VC). Paired t test and chi2 tests were used for statistical analyses.

RESULTS

We identified 29 cases of twin pregnancies discordant for SUA out of 60,989 ultrasound patients. There were no differences in the prevalence of coexisting anomalies (34% vs. 21%, p = 0.38) between the SUA fetus and the 3VC fetus. The SUA fetus was found to have significantly lower mean birth weight (1,784 +/- 765 g vs. 2,053 +/- 668 g, p = 0.001), 1-minute Apgar score (6.83 +/- 1.89 vs. 7.62 +/- 1.18, p = 0.037), and umbilical artery cord pH (7.27 +/- 0.06 vs. 7.31 +/- 0.07, p = 0.001). The SUA fetus was smaller 79% of the time (p < 0.0001). The SUA fetus achieved a significantly lower percentile (12.77% +/- 21.8 vs. 32.00% +/- 27.56, p = 0.002) when calculating the customized growth potential.

CONCLUSION

The fetus affected by an SUA in a twin gestation has impaired fetal growth and neonatal outcomes when compared to its 3VC counterpart.

Increased Apoptosis in Chorionic Trophoblasts of Human Fetal Membranes with Labor at Term

OBJECTIVE

To determine the association of apoptosis in the layers of human fetal membranes with labor at term.

STUDY DESIGN

Human fetal membranes were collected from elective cesarean sections (n = 8) and spontaneous vaginal deliveries (n = 8) at term. The extent of apoptosis within the layers of fetal membranes was determined using terminal deoxynucleotidyl transferase deoxy-UTP-nick end labeling (TUNEL) immunohistochemical assay and western blots. For TUNEL assays, 5-μm sections of formalin fixed membranes were used and the apoptotic index (number of apoptotic nuclei per total nuclei ×100) was determined in 5 independent microscopic fields. For Western blotting, proteins isolated from the amnion and choriodecidua layers were blotted against pro-apoptotic active caspase-3 and anti-apoptotic and Bcl-2. Data were expressed as the means ± SD and Student's t-test was used for statistical analysis.

RESULTS

There was no statistical difference in maternal age, gestational age, gravidity, parity, race, and smoking between patients who delivered at term via either elective cesarean or vaginally. Apoptotic index in chorionic trophoblasts of membranes obtained after vaginal delivery was higher than those obtained from elective cesarean (11.57 ± 4.98 % and 4.05 ± 2.4 % respectively, p = 0.012). The choriodecidua layers after vaginal deliveries had higher expression of the pro-apoptotic active caspase-3 and less expression of the anti-apoptotic BcL-2 than those obtained from elective cesarean sections.

CONCLUSIONS

Labor at term is associated with increased apoptosis in chorionic trophoblast cells of human fetal membranes. The cause-effect relation between apoptosis in fetal membranes and labor warrants further investigations.

Disseminated Intravascular Coagulation, Hemoperitoneum, and Reversible Ischemic Neurological Deficit Complicating Anaphylaxis to Prophylactic Antibiotics during Cesarean Delivery: A Case Report and Review of Literature

Routine use of prophylactic antibiotics reduces the risk of postcesarean fever and infections by over 50% in both nonelective and elective (scheduled) procedures. Although anaphylaxis to prophylactic antibiotics is rare, potentially fatal complications might occur. Herein, we present a case where disseminated intravascular coagulation and reversible ischemic neurological deficit complicated anaphylactic reactions to prophylactic antibiotics administered during cesarean delivery. A 27-year-old gravida 9, para 7 at 39(2)/7 weeks underwent elective repeat cesarean delivery and bilateral tubal ligation. Her surgery was complicated by intraoperative hypotension, generalized itching, and urticarial skin rash consistent with anaphylactic reaction upon administering prophylactic cefazolin. In the recovery room, she continued to be hemodynamically unstable despite energetic resuscitation. Hemoperitoneum was suspected, and laboratory evaluation indicated disseminated intravascular coagulation. Abdominal exploration revealed massive hemoperitoneum, but there was no source of active bleeding noted. The postoperative course was complicated by reversible ischemic neurological deficit, which resolved on expectant management. Disseminated intravascular coagulation and reversible ischemic neurological deficit may complicate anaphylactic reaction to prophylactic antibiotics administered during cesarean delivery. Immediate recognition and intervention is crucial for a successful outcome.

Systemic lupus erythematosus presenting with leukocytoclastic vasculitis and seizure during pregnancy

Systemic lupus erythematosus (SLE) is a rare multisystem disease with a wide array of presentation and is a diagnostic challenge during pregnancy. A 20-year-old gravida 1 at 39 weeks' gestation was referred to our hospital for elevated blood pressure, headache, and history of seizure. She was admitted with the impression of severe preeclampsia. Intravenous magnesium sulfate for seizure prophylaxis and oxytocin for induction of labor were started. Primary lower-segment cesarean section was performed for nonreassuring fetal heart tracing. The postoperative course was complicated with fever requiring prolonged intravenous antibiotic therapy, appearance of violaceous skin lesions on the periungual areas of fingers and toes, recurrent seizures, and altered sensorium. Biopsy of the lesions revealed leukocytoclastic vasculitis (LCV) with thrombi. Laboratory workup confirmed SLE with a dramatic improvement of the patient's condition upon initiating intravenous steroid therapy. LCV and neuropsychiatric SLE are rare presentations of SLE during pregnancy, and obstetricians should be aware of them. Workup for SLE is warranted in cases with atypical presentation of preeclampsia that does not resolve with delivery.

Treatment with an inhibitor of catechol-O-methyltransferase activity reduces preterm birth and impedes cervical resistance to stretch in pregnant rats

Catechol-O-methyltransferase (COMT) enzyme catalyzes the methylation of the 2- or 4-hydroxyestrogens to 2- or 4-methoxyestrogens. Both the hydroxyestrogens and methoxyestrogens have been shown to block or enhance the effects of estrogen respectively. Our objective was to investigate the potential role of COMT in parturition and cervical ripening using a rat model. Immunohistochemistry was conducted to detect and localize the COMT protein in rat uterine tissues during pregnancy. We measured the longitudinal changes in urinary 2-hydroxyestrogen before, during, and after pregnancy in rats. Animal studies were conducted to determine the effect of treatment with a selective COMT inhibitor on (1) mifepristone-induced preterm birth and (2) cervical resistance to stretch in pregnant rats. The intensity of staining for the COMT protein differed within the luminal epithelium, uterine gland epithelium, endometrium, and myometrium during pregnancy. Levels of staining for the COMT protein in rat myometrium were highest on day 1 and lowest on days 8 and 13, but high levels returned by days 16 and 19 of pregnancy. The levels of urinary 2-hydroxyestrogen gradually increased in the first 2 weeks of pregnancy, peaked from days 16 to 18 of pregnancy, and then gradually returned to pre-pregnancy levels after delivery. The percentage of pups retained in the uterus of pregnant rats treated with both mifepristone and COMT inhibitor (48 ± 15%) was significantly higher (P< 0.05) when compared with the value of pregnant rats treated with mifepristone alone (12 ± 4%). The resistance to stretch was significantly higher (P< 0.05) in cervical tissues from the pregnant rats treated with COMT inhibitor (0.28) when compared with cervical tissues taken from rats treated with vehicle control (0.18). Modulation of COMT activity may play a role in the regulation of myometrial contractility and cervical ripening during pregnancy.

Fetal origin of adverse pregnancy outcome: the water disinfectant by-product chloroacetonitrile induces oxidative stress and apoptosis in mouse fetal brain

Epidemiological studies indicate a relationship between water disinfectant by-products (DBP) and adverse pregnancy outcomes (APO) including neural tube defects. These studies suggest that fetal brain may be vulnerable to DBP during early stages of development. Therefore, we examined several molecular markers commonly known to indicate chemical-induced neurotoxicity during fetal brain development following prenatal exposure to the DBP; chloroacetonitrile (CAN). Pregnant mice, at gestation day 6 (GD6), were treated with a daily oral dose of CAN (25 mg/kg). At GD12, two groups of animals were treated with an i.v. tracer dose of [2-14C]-CAN. These animals were sacrificed at 1 and 24 h after treatment and processed for quantitative in situ micro-whole-body autoradiography. The remaining groups of animals continued to receive CAN. At GD18, control and treated animals were weighed, anesthetized, and fetuses were obtained and their brains were removed for biochemical and immunohistochemical analyses. Whole-body autoradiography studies indicate a significant uptake and retention of [2-14C]-CAN/metabolites (M) in fetal brain (cerebral cortex, hippocampus, cerebellum) at 1 and 24 h. There was a 20% reduction in body weight and a 22% reduction in brain weight of fetuses exposed to CAN compared to controls. A significant increase in oxidative stress markers was observed in various fetal brain regions in animals exposed to CAN compared to controls. This was indicated by a 3- to 4-fold decrease in the ratio of the reduced to oxidized form of glutathione (GSH/GSSG), increased lipid peroxidation (1.3-fold), and increased 8-hydroxy-2-deoxyguanosine levels (1.4-fold). Cupric silver staining indicated a significant increase in the number of degenerating neurons in cortical regions in exposed animals. In animals exposed to CAN there was increase in nuclear DNA fragmentation (TUNEL staining) detected in the cerebral cortex and cerebellum (2-fold increase in apoptotic indices). Caspase-3 activity in cerebral cortex and cerebellum of treated animals were also increased (1.7- and 1.5-fold, respectively). In conclusion, this study indicates that CAN/M crossed the placenta and accumulated in fetal brain tissues where it caused oxidative stress and neuronal apoptosis. These events could predispose the fetus to altered brain development leading to APO as well as behavioral and learning and memory deficits.

Effect of gestational age and position on peak expiratory flow rate: a longitudinal study

OBJECTIVE

We sought to study the effects of gestational age and maternal position on peak expiratory flow rates.

METHODS

Peak expiratory flow rates were measured in the standing, sitting, and supine positions in 38 healthy pregnant women at 4-week intervals starting at less than 10 weeks until delivery and again at 6 weeks postpartum. The highest reading of 3 consecutive peak expiratory flow rate measurements for each encounter and position was used in the analysis. Repeated measures analysis of covariance was performed with subjects, gestational age, position, and gestational age times position as the model effects. Least squares mean peak expiratory flow rates were compared among positions at different gestation ages using Bonferroni-adjusted least significant difference t tests.

RESULTS

Peak expiratory flow rate declined significantly throughout gestation in all positions (P < .001) with mean rate of decline of 0.65 L/min per week). The slopes of linear trends were not statistically different between positions (P = .222). However, the rate of decline for the supine position was higher than for standing and sitting positions (0.86 compared with 0.46 and 0.57 L/min per week), respectively. On average, the postpartum peak expiratory flow rate returned to 71.9% of its measurement in early gestation. Nomograms depicting mean and the 5th and 95th percentiles of peak expiratory flow rates were constructed for each position.

CONCLUSION

Peak expiratory flow rate measurements are affected by maternal position and advancing gestational age, especially in the supine position. Adjustment of patient's flow rate in relation to gestational age and maternal position is recommended, especially in pregnant women with asthma.

LEVEL OF EVIDENCE

III.

The 30-minute decision-to-incision interval for emergency cesarean delivery: fact or fiction?

The objective of this study was to evaluate the effect of the current guideline of 30-minute decision-to-incision interval (D-I) in emergent cesarean delivery (ECD) on neonatal and maternal outcomes. A retrospective chart review was conducted of pregnant women who underwent ECDs between January 1999 and December 2001. The overall median D-I was 20 minutes (range, 5 to 57 minutes). In 83 women (group I), D-I was < or = 30 minutes, and in 28 women (group II), it exceeded 30 minutes. Group I had more neonates with cord pH < 7.00, seizures, encephalopathy, and lower Apgar scores at 1 and 5 minutes than group II, but were not statistically significant. There was no significant difference in neonatal admission to the neonatal intensive care unit or length of stay between the two groups. Maternal complications were higher in group I, but not statistically significant. Although it was achieved in most of the ECDs, the guideline of 30-minute D-I does not seem to improve neonatal nor worsen maternal outcomes.

Prenatal diagnosis of a fetus with unbalanced translocation (4;13)(p16;q32) with overlapping features of Patau and Wolf-Hirschhorn syndromes

Wolf-Hirschhorn syndrome (WHS) and Patau syndrome are two of the most severe conditions resulting from chromosome abnormalities. WHS is caused by a deletion of 4p16, while Patau syndrome is caused by trisomy for some or all regions of chromosome 13. Though the etiologies of these syndromes differ, they share several features including pre- and postnatal growth retardation, microcephaly, cleft lip and palate, and cardiac anomalies. We present here a female fetus with deletion of 4p16 --> pter and duplication of 13q32 --> qter due to unbalanced segregation of t(4;13)(p16;q32) in the father. She displayed overlapping features of both of these syndromes on ultrasound. To the best of our knowledge, this is the first report of a fetus with both partial trisomy 13 and deletion of 4p16, the critical region for WHS.

Localization of the Fas-Fas ligand system in human fetal membranes

OBJECTIVE

To determine if fetal membranes might be one of the sources of Fas and Fas ligand in amniotic fluid.

STUDY DESIGN

Human fetal membranes from elective cesarean section (n = 6) were fixed in paraformaldehyde. Rolls of paraffinembedded fetal membranes were cut into 5-micron sections. After blocking with horse and goat sera, sections were incubated overnight with primary antibodies followed by the appropriate secondary antibodies. Avidin-biotin complex and diaminobenzidine were used for immunoperoxidase localization. Expression of Fas and Fas ligand was read by light microscopy.

RESULTS

Both Fas and Fas ligand were localized in amnion, chorion and decidual layers. In amnion, Fas and Fas ligand were expressed predominantly in epithelial cells and fibroblasts, while there was no immunostaining in the subepithelial compact connective tissue. In the chorion, the expression was mainly in the chorionic trophoblast, with inconsistent expression in the reticular layer. In the decidua, the expression of Fas and Fas ligand was less prominent than in amnion and chorion.

CONCLUSION

Localization of Fas and Fas ligand in human fetal membranes suggests that fetal membranes could be one of the sources of soluble Fas and Fas ligand in amniotic fluid.

Intraplacental smooth muscle tumor. A case report

BACKGROUND

Chorioangioma is the leading diagnosis for circumscribed placental lesion noted on ultrasound. Other rare intraplacental tumors may have a significant clinical impact on the mother and fetus.

CASE

An intraplacental, hypoechoic area consistent with chorioangioma was noted on ultrasound examination at 17 weeks' gestation. The lesion remained stable in size throughout gestation, with no evidence of fetal hydrops or polyhydramnios. At term, a live-born male infant was delivered vaginally, followed by spontaneous expulsion of the placenta. Histologic examination of the placenta revealed an intraplacental, potentially malignant smooth muscle tumor. Six weeks postpartum, total abdominal hysterectomy and pelvic node sampling were performed. No residual disease was found on the final histologic examination.

CONCLUSION

Although ultrasound differentiation is difficult, rare nontrophoblastic tumors should be considered in the differential diagnosis of placental masses. To our knowledge, this is the first report of such a lesion in the placenta.