Wegener's granulomatosis complicated by pregnancy. A case report

A 23-year-old woman who presented in the 17th week of her third intrauterine pregnancy was diagnosed as having active Wegener's granulomatosis. Therapy, consisting of corticosteroids, cyclophosphamide and hemodialysis, was instituted and maintained until delivery. Although Wegener's granulomatosis complicated by pregnancy has been reported previously, this is the first reported patient to be treated successfully with the above agents during the second and third trimesters without apparent harm to her or her infant.     

Serious pregnancy complications in a patient with previously undiagnosed carnitine palmitoyltransferase 1 deficiency

Fetal defects in mitochondrial beta-oxidation have been linked with an increased risk for acute fatty liver of pregnancy and preeclampsia-related conditions. A woman with previously undiagnosed carnitine palmitoyltransferase 1 deficiency experienced hemolysis, elevated liver enzymes, low platelets-like syndrome late in her first pregnancy with an unaffected fetus. Carnitine palmitoyltransferase 1 deficiency should be considered as a potential cause of life-threatening complications of pregnancy.     

Relapse of acute lymphoblastic leukemia in pregnancy: survival following chemoirradiation and autologous transfer of interleukin-2-activated stem cells.

Four cases of relapse of acute lymphoblastic leukemia (ALL) in pregnancy have been reported previously. During the past 2 decades, ALL has become curable in a majority of children, many of whom have entered their reproductive years. Thus, additional occurrences of relapsing ALL during pregnancy can be anticipated. We present the fifth case in the English-language medical literature of recurrent ALL in pregnancy. A 20-year-old woman with ALL experienced a relapse during the third trimester of her first pregnancy. Reinduction therapy was started with vincristine and prednisone and the baby was delivered 3 weeks later. Umbilical cord blood was collected and stored. The patient then received intensive chemotherapy with whole body radiotherapy and autologous peripheral blood stem cell rescue. The ALL has been in second remission for 22 months. Our patient is the only current survivor of a relapse of ALL during pregnancy. In addition, the collection of umbilical cord blood from a pregnant woman with leukemia has not been reported previously.     

Pregnancy and Lactation following Anorexia and Bulimia

Ten years after her battle with anorexia nervosa and bulimia began, a 26-year-old woman restored her normal body weight to 102 pounds from a low of 47 pounds (21.3 kilograms), became pregnant, delivered a healthy infant at term, and was successfully breastfeeding at five months. Her dietary intake, which was computer analyzed and compared with the recommended dietary allowances for pregnancy and lactation, revealed few nutrient deficiencies. Ample pregnancy weight gain provided an energy reserve for lactation.     

Promoting healthy timing and spacing of pregnancy with young married women in Northern Nigeria: a short report

The persistence of early and closely spaced pregnancies in Northern Nigeria contributes to maternal and child morbidity and mortality. A technical working group to WHO recommended that following a birth, a woman should space her next pregnancy by at least 24 months, and following a miscarriage or abortion, a woman space her next pregnancy by at least six months. UNICEF, UNFPA and WHO also recommend that a woman delay her first pregnancy until 18. These recommendations comprise the concept of Healthy Timing and Spacing of Pregnancy. The Extending Service Delivery Project (ESD) partnered with the Federation of Muslim Women Association of Nigeria and religious leaders to educate communities about the benefits of using family planning to practice HTSP in five local government areas. Informal discussions with 148 women and 28 men found high recall of the HTSP recommendations and favorable attitudes toward spacing and family planning although many remain concerned about the side effects of contraceptive methods.     

Donation of fertilized uterine ova to infertile women

Nonsurgical recovery of a preimplantation conceptus from the uterus of a fertile donor woman with transfer to an infertile recipient woman and subsequent pregnancy has been described previously. In this report, we describe the performance of 56 nonsurgical uterine lavages, recovery of 23 ova, and transfer of 17 ova with production of 8 viable pregnancies. Four pregnancies resulted in healthy infants, two aborted, and two are progressing normally. We describe a case of a woman donating an ovum to her sister, with birth of a healthy child. We also describe a viable pregnancy resulting from nonsurgical ovum transfer to a woman with no ovaries. Donation of ova by uterine lavage is a new method of overcoming human infertility; it is nonsurgical, has a low complication rate, and may be repeated several times until it produces pregnancy.     

Hydrops fetalis and stillbirth in a male glucose-6-phosphate dehydrogenase-deficient fetus possibly due to maternal ingestion of sulfisoxazole; a case report

A woman pregnant with her second child was given sulfisoxazole (Gantrisin) during her eighth month of pregnancy for a urinary tract infection. Her 34-week-old male infant was stillborn with hydrops fetalis and severe anemia. The mother was found to be glucose-6-phosphate-dehydrogenase (G-6-PDH) deficient. Ingestion of the drug which is known to produce hemolysis in G-6-PDH-deficient people may have compromised the male infant by creating an abundance of bilirubin via massive hemolysis and also retarding its elimnation by competing with bilirubin for albumin-binding sites. This case identifies a newly recognized danger in the use of sulfonzmides in the third trimester of pregnancy.     

Projective identification and denial of pregnancy--considerations of the reasons and background of unrecognized pregnancy also undiagnosed by a physician

BACKGROUND: In denial of pregnancy, the pregnant woman does not consciously perceive the pregnancy and, in extreme cases, awareness occurs only during delivery. The attending physicians also often fail to recognize the pregnancy, even though the somatic complaints leading to consultation with a physician are typically pregnancy associated. This "iatrogenic participation" was described in the earliest historical publications. Different theories are presented in this paper to elaborate this phenomenon. Elementary deficiencies in perception or incompetence do not explain most cases. PATIENTS AND METHODS: Twenty five women with denial of pregnancy, interviews PSYCHODYNAMIC EXPLANATIONS: Based on the deep-rooted subjective attitude of not being pregnant, the pregnant woman is able to include family, friends, and associates into the denial of pregnancy mindset. In a similar way, she is able to influence her doctor. The woman's autosuggestive wishful notions of not being pregnant receive suggestive confirmation by the physician's misdiagnosis and lead to a continuing denial of pregnancy. PROJECTIVE IDENTIFICATION: In 1946, M. Klein introduced this term to describe a certain defense mechanism relating to fantasies and accompanying object relationships. The self initially successfully disposes of unwanted aspects, splits them off, and transfers them to another person, to finally reclaim them in a modified form. Certain elements of this psychoanalytical concept can characterize the interaction between physician and pregnant woman, which, in the case of denied pregnancies, does not lead to a diagnosis of pregnancy. Through projection, the pregnant woman is capable of manipulating the physician so that he perceives her, according to her wishes, as not being pregnant and misdiagnoses her correspondingly as "service in return". Opportunities for more mature handling of the denied content in terms of psychological development through accurate diagnosis of the pregnancy are indicated.     

Postpartum hypokalemic paralysis.

An attack of hypokalemic paralysis occurring in a 23-year-old woman during the immediate postpartum period of her fourth pregnancy is described. A flaccid paralysis of her extremities and markedly diminished deep tendon reflexes developed 3 hours after delivery, at which time her serum potassium level was found to be 1.7 mEq/liter. Hypokalemic paralysis has not been previously reported as an immediate postpartum complication. The pathophysiology and management of this condition are discussed, as are the treatment and follow-up of this specific patient.     

Microchimerism: Defining and redefining the prepregnancy context – A review

Bidirectional transplacental exchange characterizes human pregnancy. Cells exchanged between mother and fetus can durably persist as microchimerism and may have both short- and long-term consequences for the recipient. The amount, type, and persistence of microchimerism are influenced by obstetric characteristics, pregnancy complications, exposures to infection, and other factors. A reproductive-aged woman enters pregnancy harboring previously acquired microchimeric “grafts,” which may influence her preconception health and her subsequent pregnancy outcomes. Many questions remain to be answered about microchimerism with broad-ranging implications. This review will summarize key aspects of this field of research and propose important questions to be addressed moving forward.     

Care of the woman with hypertension in pregnancy: the viewpoint of the midwife.

Key principles underpin good midwifery care of every pregnant woman, including a sound knowledge base, meeting the woman's needs and enhancing care. Normal antenatal care, with regular measurement of blood pressure, remains the mainstay of screening for hypertension in pregnancy. The midwife's role is that of accurate assessment and communication when detecting the first signs of hypertension. The midwife will then play a major role in the ongoing monitoring of the condition, liaison with the medical team and education of the woman and her family. Continuity of care is an important principle in avoiding errors in recording blood pressure between care givers; familiarity of a known midwife may reduce the likelihood of white coat hypertension. Advocacy should be employed by the midwife as a key link between the woman, her family and the obstetric team. Every woman who has experienced pre-eclampsia should be given the opportunity to talk through her care at a later date. This may be at the postnatal appointment or through a debriefing service.     

Successful Pregnancy in an Adolescent Woman with a Communicating Double Uterine Anomaly

BACKGROUND: Women with communicating double uterine anomalies are at increased risk for obstetric complications, including early pregnancy loss, preterm delivery, and breech presentation. We present the pregnancy of a woman with a previously diagnosed communicating double uterine anomaly. CASE: An 18-yr-old white female with a previous diagnosis at age 11 of a communicating double uterus, double cervix, and obstructed left hemivagina was followed during the course of her pregnancy. She experienced no complications until 36 6/7 weeks, when she was found to have signs and symptoms of mild preeclampsia. The fetus was in a breech presentation and a cesarean section was performed. Two hemiuteri were identified intraoperatively. The communication was not visualized. A viable male infant was delivered without complications. CONCLUSION: This patient represents only the sixth report of successful pregnancy in a woman with a Toaff type 5A communicating uterine anomaly.     

Hereditary protein C deficiency during pregnancy

Hereditary protein C, a primary hypercoagulable state, has not been previously associated with preeclamptic toxemia. A woman with previous preeclamptic toxemia and fetal deaths presented with recurrent deep vein thrombosis during her third pregnancy. Hereditary protein C was diagnosed but full heparinization followed by low-dose heparin failed to prevent preeclamptic toxemia.     

Successful management of cervical pregnancy with medical intervention only: a case report

BACKGROUND: Cervical pregnancies are a rare form of ectopic pregnancy. They frequently present with hemorrhage and require hysterectomy to control bleeding. Their incidence may be higher with in vitro fertilization than previously considered. Since future fertility is desired in these patients, conservative management is frequently attempted. Increased early surveillance leads to earlier diagnosis and intervention. Most case reports to date indicated treating with either medical and surgical intervention or surgical intervention. CASE: A 36-year-old woman presented with recurrent pregnancy loss and tubal disease. In vitro fertilization was recommended. Embryo transfer resulted in a cervical pregnancy. She experienced painless vaginal bleeding shortly after her positive pregnancy test. A cervical pregnancy was diagnosed by early ultrasound. The patient underwent successful medical management and complete resolution with methotrexate alone. CONCLUSION: Cervical pregnancy, when diagnosed early, can be successfully treated with medical therapy.     

Successful outcome in pregnancy complicated by prior uterine rupture: a report of two cases

Background

Rupture of the uterus, especially in a scarred uterus, intrapartum is well known. The risk of uterine rupture in women with a previous lower segment caesarean section is 0.2–1.5%, whereas in an unscarred uterus it is extremely rare.

Case

Case 1 A 26-year-old woman in her third pregnancy was referred at 16 weeks from a community hospital. She had a history of uterine perforation at the fundus in her first pregnancy during a dilatation and curettage requiring laparotomy and repair. In her second pregnancy, fetal death had occurred in the second trimester. She conceived subsequently and in her third pregnancy, the risk of silent rupture of uterus was explained, but the couple opted for continuation of this pregnancy.Case 2 A 25-year-old woman in her third pregnancy was referred. In her first pregnancy, she had a septic abortion during the fifth month of pregnancy. Two years later, she presented at 16 weeks gestation with a severe abdominal pain. An ultrasound/MRI revealed a uterine wall defect with an empty uterus, fetus lying outside the uterine cavity with moderate free fluid. In her third pregnancy, 18 months later, at 10 weeks gestation an ultrasound revealed a single live intrauterine pregnancy with an indistinct thinning and sacculation of the fundo-posterior uterine wall.

Conclusion

With increasing caesarean rates, every obstetrician is bound to face the challenge of this life-threatening obstetric hazard and must be prepared to handle this emergency with an expeditious recourse to laparotomy.

     

Fetal congenital complete heart block: prophylaxis with intravenous gammaglobulin and treatment with dexamethasone

We report a case of complete fetal heart block in a 35-year-old Chinese woman known to be positive for anti-SSA/Ro and anti-SSB/La antibodies. She had fetal hydrops leading to intrauterine death in her first pregnancy Prophylactic intravenous immunoglobulin, given at 14 and 18 weeks' gestation, as well as oral dexamethasone, commenced at 24 weeks' gestation, allowed continuation of the pregnancy until 34 completed weeks of gestation. An external pacemaker was inserted in the baby on the first day of life. Two-and-a-half months later, a permanent pacemaker was inserted.     

A 59-year-old woman gives birth to twins--when should a fertility specialist refuse treatment?

OBJECTIVE: To review cases of infertility where despite extremely low odds of success and potential risks to the woman if she became pregnant or to the fetus, the couples elected to take a chance to fulfill their dreams of having a baby. MATERIALS AND METHODS: Six cases are described: case 1, a 59-year-old woman with hyperstimulation and intramuscular fibroids compressing the uterine cavity who wanted to be a donor egg recipient; case 2, a 59-year-old woman desiring a second transfer of sibling frozen embryos who had previously conceived with donor eggs at age 57; case 3, a 33-year-old woman with a subseptated uterus and cervical abnormality from intrauterine diethilstibesterol exposure plus hemoaphilia trait, and only 25% of her liver remaining from a previous partial liver resection; case 4, a woman with an unicornuate uterus refusing reduction of her twins to a singleton; case 5, a 39-year-old woman willing to try again to have her first live born child with a history of a large macroprolactinoma that was resected but markedly enlarged in her previous pregnancy despite bromocryptine therapy; and, case 6, a woman willing to try a unique experimental therapy with extremely high thyroid stimulating immunoglobulins to inhibit severe intrauterine growth retardation and potential premature synostosis for her condition of Hashimoto's disease. RESULTS: Cases 2-5 all had successful outcomes. Case 1 was never given the chance for donor oocytes since she was rejected by a majority vote of our physicians because of the fear of a malpractice suit. DISCUSSION: If a couple understands the potential risks and the low odds of success, they should be given the opportunity to fulfill their dreams of having a baby. However, treating physicians are under no obligation to take malpractice risks.     

Gynaecological malignancies in pregnancy

PURPOSE OF REVIEW: To review the management of gynaecological cancers occurring in association with pregnancy. To consider the impact of the cancer on the pregnancy, and the impact of the pregnancy on the cancer. RECENT FINDINGS: The management of gynaecological cancers in pregnancy remains, fortunately, a rare problem for the gynaecological oncology team. This inevitably means that many management decisions will be informed by relatively small case series and case reports. There have been interesting reports where pregnancy has been prolonged to achieve fetal viability in both cervix and ovary cancer in pregnancy, and these are discussed below. SUMMARY: Any cancer in pregnancy is a catastrophic event for the woman and her partner, and poses great challenges for the multidisciplinary team responsible for her care. Gynaecological cancers in pregnancy are even more stressful as the woman will naturally worry about the survival of her baby, and the implications for her future fertility. Fortunately the outcome for most women and their babies is favourable.     

Pruritic urticarial papules and plaques of pregnancy presenting in the postpartum period: a case report

BACKGROUND: Pruritic urticarial papules and plaques of pregnancy (PUPPP), also known as polymorphic eruption of pregnancy, is the most common dermatosis of pregnancy. It usually evolves in the third trimester and resolves rapidly postpartum. CASE: A 25-year-old woman complained of an intensely pruritic rash for 2 days. The rash began 10 days postpartum. It began on her abdomen and spread to her buttocks, legs and upper arms. On examination, erythematous papules and urticarial plaques were present in the striae of the abdomen and buttocks and involved the legs, arms and back. No excoriations, vesicles or pustules were present, and there was sparing of the face, palms and soles. The patient was treated with fexofenadine, hydroxyzine, oatmeal baths and cool compresses. Follow-up 2 days later revealed a worsening rash and persistence of severe pruritus. At that time the patient was placed on prednisone, which led to relief of her symptoms and clearing of the rash. DISCUSSION: PUPPP is reported to develop in 0.5% of pregnancies. MEDLINE searches of the literature from 1966 to 2003 using the keywords pruritic urticarial papules and plaques of pregnancy or polymorphic eruption of pregnancy and postpartum revealed only 2 other cases of PUPPP developing in the postpartum period. Although the clinical presentation of this patient was typical of that of PUPPP, it demonstrates an unusual time course with its postpartum presentation. CONCLUSION: Dermatoses of pregnancy should remain in the differential diagnosis of rash even weeks after a woman delivers.     

Live birth of twins after IVF of oocytes that were cryopreserved almost 12 years before

A 45-year-old woman received embryos from IVF by intracytoplasmic sperm injection (ICSI) with her own oocytes that were cryopreserved (slow freezing in a low-sodium medium) 11 years and 7 and a half months before, when she was 33 years old. From seven metaphase-II oocytes thawed, five survived, four were fertilized after ICSI and two cleaving embryos were transferred on day 3. A diamniotic dichorionic term pregnancy was achieved, ending with the delivery of two healthy girls. As far as is known, this case represents, to date, the longest storage period of cryopreserved human oocytes resulting in a live birth.