An Unusual Complication in a Twin Pregnancy — Umbilical Cord of Twin 2 Around the Neck of Twin 1

Summary: A case of uniovular twin pregnancy is described in which the cord of twin 2 around the neck of twin 1 was clamped and cut soon after delivery of the head of twin 1, thereby creating an unusual obstetric emergency.     

An Unusual Set of Triplets: Twin Intrauterine Pregnancy with Singleton Extrauterine Pregnancy

Heterotopic pregnancy (simultaneous intrauterine and extrauterine pregnancy) is an extremely rare clinical phenomenon occurring approximately 1 in 30,000 pregnancies (1) or 1 in 2,000,000 live births (2). There have been 435 cases reported in the world literature up to 1956 (3). Simultaneous viability in heterotopic pregnancy is an even rarer event occurring in only 10.6% of cases (3).     

脐带附着方式及双胎间胎膜皱褶在双胎输血综合征早期预测中的作用

目的:探索脐带附着方式及双胎间胎膜皱褶在双胎输血综合征(TTTS)发生中的预测价值。方法:选择2011年1月至2015年1月在昆明医科大学第一附属医院妇产科行产前检查并最后确诊的单绒毛膜双羊膜囊(MCDA)双胎的孕妇136例为研究对象,患者均接受产前超声检查,且被追踪到妊娠结局,其中TTTS组20例,非TTTS组116例。分析两组患者的彩色频谱多普勒超声检测脐带的附着方式及双胎间胎膜皱褶(孕15~17周)情况。结果:TTTS组脐带附着不一致发生率25.0%(5/20)高于非TTTS组8.6%(10/116),差异有统计学意义(P0.05);脐带附着不一致者发生TTTS的风险高于脐带附着一致者(OR 3.553,95%CI 1.062~11.754)。脐带附着不一致预测TTTS的敏感性、特异性、阳性预测值和阴性预测值分别为25.0%、91.4%、33.3%及87.6%。TTTS组和非TTTS组双胎间胎膜皱褶发生率分别为25.0%(5/20)和16.4%(19/116),差异无统计学意义(P0.05)。结论:在MCDA双胎中,一胎儿中央附着,另一胎儿为边缘附着或帆状附着的,脐带附着不一致是TTTS发生的危险因素,脐带附着不一致预测TTTS的特异性及阴性预测值较高;双胎间胎膜皱褶未显示出对TTTS的预测价值。     

脐带真结的产科因素及妊娠结局

目的:探讨脐带真结的危险因素及其妊娠结局。方法:回顾性分析2000年1月至2005年7月间分娩的脐带真结孕妇17例。结果:脐带真结的发生率为0.24%。Logistic回归相关分析发现脐带真结的发生与男性胎儿、羊水过多、脐带绕颈、脐带过长有关。脐带真结胎儿发生死胎、胎儿窘迫、剖宫产的风险较无脐带真结者明显增加(P<0.01)。结论:怀有男性胎儿、脐带过长、脐带绕颈、羊水过多的孕妇发生脐带真结的风险增加,应仔细地进行B超和彩色多普勒检查以排除脐带真结可能。     

Marked Growth Discordancy in Three Sets of Twins Associated with Velamentous Insertion of the Umbilical Cord of the Smaller Twin

The incidence of velamentous insertion of the umbilical cord is increased in multiple gestations. In singleton and twin gestations, this condition has been associated with lower mean birth-weight. We present three sets of twins (two monozygotic and one dizygotic) in which marked growth discordancy, ranging between 25 and 50%, was associated with velamentous insertion of the umbilical cord of the smaller twin in the absence of any other obvious pathology. In cases of marked growth discordancy in twins, velamentous insertion should be considered a possible etiology, and sonographic inspection of the placental insertion of the umbilical cord, particularly of the smaller twin, performed.     

Urinary Hydroxyproline in Pregnancy — An Index of Placental Function A Preliminary Report

Summary: The range of total urinary hydroxyproline was determined by 71 assays on 36 women with normal pregnancies. In addition, 103 assays were performed on 58 women with complicated pregnancies. There was a gradual increase in values up to 36 weeks in normal pregnancy, with a fall towards term. In patients with placental insufficiency due to such conditions as marked hypertension and diabetes, high values were obtained in those with a successful outcome of the pregnancy, which seemed to be indicative of compensatory increased vascularity of the placenta. A lack of this rise was seen in those in whom intrauterine death occurred. It is suggested that total urinary hydroxyproline assay may be useful as an additional parameter for assessing placental function.     

Differential Transmission of Adenovirus in a Twin Pregnancy

Background: Intrauterine adenovirus infection has been associated with nonimmune hydrops. We describe a twin pregnancy in which adenovirus was demonstrated by polymerase chain reaction in the amniotic fluid of one twin afflicted by hydrops. Adenovirus was absent in the amniotic fluid of the other twin.Case: A 25-year-old, gravida 3, para 1, with twin gestation at 20 weeks’ gestation was noted on ultrasound anomaly screen to have hydrops associated with twin B. Polymerase chain reaction analysis of amniotic fluid revealed adenovirus in twin B with none noted in twin A. At 26 weeks’ gestation both infants died.Conclusion: This case demonstrates differential transmission of adenovirus in a twin pregnancy. One twin developed hydrops fetalis possibly secondary to adenovirus infection.     

Thyroxine Abuse: An Unusual Case of Thyrotoxicosis in Pregnancy

Summary: Eating disorders and the associated behavioural problems and drug abuse are uncommon in pregnancy. When they do occur they are often unrecognized because of denial but when significant may pose a risk to both the mother and her fetus. This case illustrates a number of problems that may be encountered in women with eating disorders in pregnancy, including prolonged and recurrent metabolic disturbances and diuretic abuse. In particular it illustrates the derangements of thyroid function seen in pregnant women with eating disorders and reminds us that when a cause for thyrotoxicosis remains obscure, thyroxine abuse should be considered and explored.     

Umbilical Cord Plasma Glutathione S-Transferase Alpha 1-1 Levels as a Marker of Neonatal Hepatocellular Integrity

Objective: To investigate possible delivery-related impaired neonatal hepatocellular integrity by assessment of arterial and venous umbilical cord plasma levels of glutathione S-transferase Alpha 1-1.Methods: Glutathione S-transferase Alpha 1-1 levels were assessed in arterial and venous umbilical cord, and maternal venous plasma samples. The influence of maternal, delivery, and neonatal characteristics on arterial umbilical cord glutathione S-transferase Alpha 1-1 levels was studied, using linear regression analysis after log-transformation.Results: Median (range) arterial umbilical cord glutathione S-transferase Alpha 1-1 plasma levels were higher than venous umbilical cord levels (9.68 [0.64–1125] μg/L and 7.66 [0.78–987.5] μg/L, respectively, P < .005). Median (range) arterial and venous umbilical cord glutathione S-transferase Alpha 1-1 levels were higher than, and did not correlate with, maternal venous plasma levels (8.79 [1.79–183] μg/L and 6.47 [1.58–164.5] μg/L versus 1.47 [0.46–10.4] μg/L, P < .001). Neonates born vaginally demonstrated higher median (range) levels than those delivered by cesarean (13.41 [1.02–1125] μg/L and 5.73 [0.64–172.90] μg/L, respectively, P < .001). Neonates with unfavorable pH (arterial pH under 7.20) demonstrated higher median (range) levels than those with normal pH (arterial pH at least 7.20) (15.15 [0.77–1125] μg/L and 8.82 [0.64–120.90] μg/L, respectively, P < .001). Stepwise multiple linear regression analysis showed that birth weight had the largest influence on arterial umbilical cord glutathione S-transferase Alpha 1-1 levels, followed by arterial base deficit, and route of delivery.Conclusion: Arterial umbilical cord glutathione S-transferase Alpha 1-1 plasma levels, being unrelated to maternal venous levels, might give a reliable impression of early neonatal hepatocellular integrity and may become an additional indicator of neonatal condition immediately after birth.     

Centrality of the Umbilical Cord Insertion in a Human Placenta Influences the Placental Efficiency

GoalWe assess the effect on placental efficiency of the non-centrality of the umbilical cord insertion and on chorionic vascular distribution to determine if cord centrality measurably affects placental function as reflected in birth weight.Materials and methods1225 placentas collected from a prospective cohort had digital photographs of the chorionic plate. Of these, 1023 were term, 44 had velamentous cord insertion and 12 had missing clinical data, leaving N = 967 (94.5%) cases for analysis. Mathematical tools included a dynamical stochastic growth model of placental vasculature, Fourier analysis of radial parameterization of placental perimeters, and relative chorionic vascular density (a measure of “gaps” in the vascular coverage) derived from manual tracings of the fetal chorionic surface images. Bivariate correlations used Pearson's or Spearman's rank correlation as appropriate, with p < 0.05 considered significant.ResultsThe correlation of the standard deviation of the placental radius (a measure of non-roundness of the placenta) with cord displacement was negligible (r = 0.01). Empirical simulations of the vascular growth model with cord displacement showed no deviation from a normal round-to-oval placental shape for cord displacement of 10–50% of placental radius. The correlation of the metabolic scaling exponent β with cord displacement measured by Fourier analysis is 0.17 (p < 0.001). Analysis of the chorionic vascular density in traced images shows a high correlation of the relative vascular distance with cord displacement: 0.59 in one set of 12 images, and 0.20 in the other set of 28 images.ConclusionNon-central cord insertion has little measurable correlation with placental shape in observed or simulated placentas. However, placentas with a displaced cord show a markedly reduced transport efficiency, reflected in a larger value of β and hence in a smaller birth weight for a given placental weight. Placentas with a non-central cord insertion have a sparser chorionic vascular distribution, as measured by the relative vascular distance. Even if typically a placenta with a non-central insertion is of a normal round shape, its vasculature is less metabolically effective. These findings demonstrate another method by which altered placental structure may affect the fetal environment, influencing birth weight and potentially contributing to later health risks.     

Laparoscopic Pelvic Lymphadenectomy in a Patient with Cervical Cancer Stage Ib1 Complicated by a Twin Pregnancy

Cervical cancer is the most frequently observed malignancy during pregnancy. The presence of nodal metastasis is the most important negative predictor factor, and its assessment is crucial in deciding whether the pregnancy can safely continue. To our knowledge, this is the first report of a twin pregnancy complicated by cancer of the uterine cervix that was sucessfully treated with laparoscopic pelvic lymphadenectomy and subsequently with neoadjuvant chemotherapy. A 35-year-old woman, gravida 2, para 1, with a dichorionic-diamniotic twin pregnancy underwent laparoscopic staging of the pelvic lymph nodes at 17 weeks of gestation. Cervical adenocarcinoma, grade 2, stage 1b1 with lymphovascular space invasion was diagnosed. Nineteen negative nodes were removed, and the patient was counseled to continue the pregnancy. On the basis of tumor size and detection of lymphovascular space invasion, cisplatin as neoadjuvant chemotherapy was administered until week 32 of gestation, when a cesarean section delivery was performed, along with radical hysterectomy. No complications to the neonates or to the mother due to the therapy were observed. This case demonstrates the safety of operative nodal staging during gestation, even in a twin pregnancy. Exclusion of nodal metastasis may improve oncologic outcomes, and neoadjuvant chemotherapy should be administered when indicated.