Fetal Metabolic Alkalosis Resulting from Maternal Vomiting

We describe a pregnant patient with severe compulsive water ingestion and vomiting that lead to metabolic alkalosis and preterm delivery. A 21-year-old patient was hospitalized multiple times throughout pregnancy for symptoms initially thought to be related to hyperemesis gravidarum. Overtime, it became apparent that the patient induced vomiting by rapidly drinking large volumes of water. At 32 weeks' gestation, rapid ingestion of water caused 3 days of vomiting with findings of hyponatremia, hypokalemia, hypochloremia, metabolic alkalosis, and compensatory respiratory acidosis. Fetal monitoring showed minimal variability and recurrent decelerations; subsequent biophysical profile score of 2/10 prompted urgent cesarean section. A male newborn was delivered and cord blood gases reflected neonatal metabolic alkalosis and electrolyte imbalances identical to those of the mother. Compensatory hypoventilation in both mother and fetus were treated with assisted ventilation. With saline administration and repletion of electrolytes, metabolic alkalosis resolved for both patients within days. Metabolic alkalosis was transplacentally acquired by the fetus. This case demonstrates the development of metabolic alkalosis in a pregnant woman caused by vomiting severe enough to prompt preterm delivery for nonreassuring fetal status. It also demonstrates fetal dependence on both placenta and mother to maintain physiologic acid-base and electrolyte balance.

Cause for optimism in mild hypoxic ischaemic hypoxic encephalopathy

Linked article: This is a mini commentary on Törn et al., pp.1602–1609 in this issue. To view this article visit https://doi.org/10.1111/1471‐0528.17533.

Placental pathology reports: A qualitative study in a US university hospital setting on perceived clinical utility and areas for improvement

OBJECTIVE

To explore how placental pathology is currently used by clinicians and what placental information would be most useful in the immediate hours after delivery.

STUDY DESIGN

We used a qualitative study design to conduct in-depth, semi-structured interviews with obstetric and neonatal clinicians who provide delivery or postpartum care at an academic medical center in the US (n = 19). Interviews were transcribed and analyzed using descriptive content analysis.

RESULTS

Clinicians valued placental pathology information yet cited multiple barriers that prevent the consistent use of pathology. Four main themes were identified. First, the placenta is sent to pathology for consistent reasons, however, the pathology report is accessed by clinicians inconsistently due to key barriers: difficult to find in the electronic medical record, understand, and get quickly. Second, clinicians value placental pathology for explanatory capability as well as for contributions to current and future care, particularly when there is fetal growth restriction, stillbirth, or antibiotic use. Third, a rapid placental exam (specifically including placental weight, infection, infarction, and overall assessment) would be helpful in providing clinical care. Fourth, placental pathology reports that connect clinically relevant findings (similar to radiology) and that are written with plain, standardized language and that non-pathologists can more readily understand are preferred.

CONCLUSION

Placental pathology is important to clinicians that care for mothers and newborns (particularly those that are critically ill) after birth, yet many problems stand in the way of its usefulness. Hospital administrators, perinatal pathologists, and clinicians should work together to improve access to and contents of reports. Support for new methods to provide quick placenta information is warranted.

Mesenchymal Stem Cell Identification After Delayed Cord Clamping

We sought to determine the feasibility of identifying and quantifying mesenchymal stem cells (MSCs) from umbilical cord blood (UCB) after delayed cord clamping in preterm and term births. We obtained 3 mL of UCB at various gestational ages after delayed cord clamping. UCB separated by density gradient centrifugation within 4 h of delivery was passed through magnetic bead micro-columns to exclude the CD34 + cell population. The samples were incubated with fluorescent-tagged mesenchymal cell marker antibodies CD 29, CD44, CD73, CD105, and hematopoietic cell marker CD45. The cell populations were analyzed by flow cytometry. Viable cells were assessed with 7-aminoactinomycin-D. The results were expressed in median (minimum to maximum) MSCs and compared between preterm and term samples. A total of 12 UCB samples (32-40 weeks) were obtained, 10 of which demonstrated MSCs, accounting for 0.0174% (0-14.7%) of the viable UCB mononuclear cells. MSCs comprised 0.148% (0.0006-1.59%) and 0.116% (0-14.7%) of the viable UCB mononuclear cells in the term (n = 5), 38.4 ± 1.3 weeks, and preterm (n = 7) samples, 34.6 ± 1.1, respectively, p = 0.17. There was an overall median of 96 (0-39,574) MSCs. There was no difference in the median numbers of MSCs identified between term and preterm UCB samples, 3384 (23-6042) and 36 (0-39,574), respectively, p = 0.12. Mesenchymal stem cells were identified and quantified in 5 of 7 preterm and all 5 term UCB 3-mL samples obtained after delayed cord clamping.

Placental thickness on ultrasound and neonatal birthweight

Objective To investigate the relationship between maximal placental thickness during routine anatomy scan and birthweight at delivery. Methods This retrospective descriptive study analyzed 200 term, singleton deliveries in 2016 at Penn State Hershey Medical Center. We measured maximal placental thickness in the sagittal plane from the ultrasound images of the placenta obtained at the 18-21-week fetal anatomy screen. The relationship between placental thickness and neonatal birthweight was assessed using Pearson's correlation coefficient (r) with 95% confidence interval (CI). Logistic regression was used to assess the association between placental thickness and secondary binary outcomes of neonatal intensive care unit (NICU) admission and poor Apgar scores. Two-sample t-tests, or exact Wilcoxon rank-sum test for non-normally distributed data, were used to assess for differences attributable to medical comorbidities (pre-gestational diabetes, gestational diabetes, chronic hypertension, gestational hypertension, preeclampsia and eclampsia). Results Placental thickness had a positive correlation with neonatal birthweight [r=0.18, 95% CI=(0.05, 0.32)]. The mean placental thickness measured 34.2±9.7 mm. The strength of the correlation remained similar when adjusting for gestational age (r=0.20) or excluding medical comorbidities (r=0.19). There was no association between placental thickness and NICU admission, Apgar scores <7 or medical comorbidities. Conclusion Our study demonstrated a positive correlation between sonographic placental thickness and birthweight. Future prospective studies are warranted in order to further investigate whether a clinically significant correlation exists while adjusting for more covariates.

Accuracy of fetal anatomy survey in the diagnosis of velamentous cord insertion: a case-control study

Objective

Our objective was to determine the accuracy of ultrasound at the time of the fetal anatomy survey in the diagnosis of velamentous cord insertion (VCI).

Study design

This retrospective case–control study identified placentas with VCI (cases) and randomly selected placentas with normal placental cord insertion (PCI) (controls) as documented by placental pathology for mothers delivered from 2002 through 2015. Archived ultrasound images for PCI at the time of the fetal anatomy survey were reviewed. Data analysis was by calculation of sensitivity, specificity, and accuracy and their 95% CI for the ultrasound diagnosis of VCI.

Results

The prevalence of VCI was 1.6% of placentas submitted for pathologic examination. There were 122 cases of VCI and 347 controls with normal PCI. The performance criteria calculated for the diagnosis of VCI at the time of fetal anatomy survey were as follows: sensitivity 33.6%; 95% CI: 25.3, 42.7; specificity 99.7%; 95% CI: 98.4, 99.9 and accuracy 82.5; 95% CI: 80.5, 82.9.

Conclusion

The identification of a VCI at the time of fetal anatomy survey is highly specific for the presence of a VCI as documented by placental pathology. The sensitivity in this study was less than expected. Sensitivity could be improved by reducing the number of nonvisualized PCIs, creating an awareness of risk factors for VCI, and obtaining more detailed images in the case of an apparent marginal PCI.

Are gestational and type II diabetes mellitus associated with the Apgar scores of full-term neonates?

Objective

To compare Apgar scores of full-term newborns of mothers with gestational (GDM) or type II diabetes mellitus (T2DM) with scores of newborns of mothers without impaired glucose tolerance.

Study design

This was a retrospective data collection study (n=297). We reviewed 1-minute and 5-minute neonatal Apgar scores of newborns of mothers with GDM (n=100) or T2DM (n=97). Our control group consisted of newborns of mothers without a prior history of impaired glucose tolerance (n=100). ANOVA and linear model with corrected errors were used and adjusted for newborn sex and weight, and maternal age. Chi-squared analysis was performed for newborn sex.

Results

The mean 1-minute and 5-minute Apgar scores were 7.8 and 8.9 for the GDM group and 7.7 and 8.9 for the T2DM group, respectively. There was no statistical difference in the 1-minute and 5-minute Apgar scores between the GDM group and controls (P=0.89 and P=0.13, respectively) nor in the scores between the T2DM group and controls (P=0.67 and P=0.40, respectively).

Conclusion

Maternal history of GDM and T2DM does not appear to be associated with the 1-minute and 5-minute Apgar scores of full-term newborns of mothers with GDM and T2DM as compared to newborns of mothers without a history of impaired glucose tolerance.

Accuracy of signs of clinical chorioamnionitis in the term parturient

OBJECTIVE

Uniform histopathologic guidelines were applied to diagnose chorioamnionitis and estimate the accuracy of clinical signs in term parturients.

STUDY DESIGN

A retrospective cohort study utilized slides from term parturient placentas with Amniotic Fluid Infection Nosology Committee guidelines as the gold standard. Sensitivity, specificity and accuracy for fever, maternal tachycardia and fetal tachycardia were calculated.

RESULT

Of 641 placentas, 367 (57.3%) had histologic chorioamnionitis and 274 (42.7%) were negative. Fever had a sensitivity of 42%, specificity of 86.5% and accuracy of 61%. Fever, maternal tachycardia and fetal tachycardia had a sensitivity of 18.3%, specificity of 98.2% and accuracy of 52.4%.

CONCLUSION

Histologic chorioamnionitis, frequently asymptomatic, is a common finding in placentas examined from term parturients. Clinical signs are not accurate in the diagnosis. Adoption of uniform pathologic guidelines will facilitate research into the clinical significance of these lesions in the future.

Pathologic Examination of the Placenta and Observed Practice

OBJECTIVE

To estimate the percentage of deliveries eligible for pathologic examination of the placenta and compare with observed practice using the College of American Pathologists' (CAP) 1997 guidelines for examination of the placenta.

METHODS

Records were reviewed from all live-birth deliveries 20 weeks or more of gestation in 2001 at Strong Memorial Hospital. The expected number of deliveries with CAP recommended indications was determined and compared with the observed number of deliveries in which the placenta was actually examined. Descriptive statistics, independent t tests, chi(2) tests, difference between two population proportions test, odds ratios, 95% confidence intervals, and multiple logistic regression were used to analyze the data.

RESULTS

The observed number and percentage of deliveries with CAP recommended indications that had pathologic placental examination, 575 and 18.2% (95% confidence interval 16.9-19.6), was significantly lower (P<.001) than expected, 1,185 and 37.5% (95% confidence interval 35.8-39.2). The placenta was examined less frequently than expected in 9 of 14 categories. Independent predictors of examination of the placenta were gross placental abnormalities, multiple gestation, prematurity, peripartum fever, neonatal intensive care unit care of infant, cesarean delivery, and delivery by a maternal-fetal medicine specialist.

CONCLUSION

Using the CAP guidelines for submission of the placenta would result in pathologic examination in 37.5% of all deliveries. Less than one half of all deliveries in which the placenta was eligible for submission were actually examined. Current advances in our understanding of pathologic conditions of the placenta and their relation to infant outcomes may warrant re-evaluating policy on placental examination at institutional and national levels.

LEVEL OF EVIDENCE

II.

The feasibility of using histologic placental sections to predict newborn nucleated red blood cell counts

OBJECTIVE

To determine the feasibility of using calculated nucleated red blood cell (RBC) counts from histologic placental slides to predict newborn nucleated RBC counts.

METHODS

This retrospective study compared absolute nucleated RBC counts from 24 newborns, diagnosed with fetal distress in labor, with counts calculated from their histologic placental slides. A simple linear regression model was tested with newborn nucleated RBC counts as the dependent variable and calculated placental nucleated RBC counts as the independent variable.

RESULTS

The mean +/- standard deviation newborn nucleated RBC count was 4.81 x 10(9) +/- 5.46 x 10(9)/L compared with 1.37 x 10(9) +/- 1.78 x 10(9)/L calculated from placental sections. These data were normalized by logarithmic transformation. A significant linear regression was obtained, r(2) = 0.74, P <.001. The prediction equation obtained was natural logarithm (newborn nucleated RBC count) is equal to 1.002 x natural logarithm (placental nucleated RBC count) + 1.173.

CONCLUSION

It is feasible to calculate nucleated RBC counts from histologic slides of the placenta that are predictive of newborn nucleated RBC counts. Further work on more homogeneous groups of subjects is necessary to increase the precision of the method. The placenta could serve as a surrogate source for newborn whole blood nucleated RBC counts around the time of birth.

A review of HELLP syndrome

HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome is a variant of severe preeclampsia which is associated with substantial maternal and perinatal morbidity and mortality. As with preeclampsia, the etiology and pathogenesis of HELLP syndrome is not completely understood. An increase in vascular thrombosis and activation of the coagulation system may be important in the clinical presentation of this disorder. Laboratory criteria for the diagnosis of HELLP syndrome have been classically described but lack uniformity among different institutions. Aggressive management of HELLP syndrome with expeditious delivery appears to yield the lowest perinatal mortality rates. Conservative or expectant management has been associated with higher stillbirth rates with antenatal corticosteroids not causing resolution of the laboratory abnormalities. Resolution of laboratory abnormalities in HELLP syndrome runs a protracted course over several days after delivery. Despite nearly two decades since HELLP syndrome has been defined as a clinical entity, treatment for the disorder still remains delivery of the patient.

Vulvar metastasis of breast carcinoma. A case report

BACKGROUND

Metastasis of breast carcinoma to the vulva is rare: only a few cases have been previously described.

CASE

A 61-year-old woman with a history of recurrent breast carcinoma presented with a painless lump on the vulva. Excisional biopsy showed an infiltrating adenocarcinoma that was histologically similar to the primary breast tumor.

CONCLUSION

This report is another of breast carcinoma metastatic to the vulva. The clinical features and histologic findings distinguish this lesion from a primary breast carcinoma occurring in ectopic breast tissue.