Flow velocity waveforms of the fetal circulation preceding fetal death in a case of lupus anticoagulant

Flow velocity waveforms of the vascular system were evaluated at 25 weeks 2 days and 27 weeks 5 days of gestation in the case of a severely growth-retarded fetus. At the first scan, the cerebral vessels displayed low pulsatility indexes, reflecting the brain-sparing pattern that characterizes fetal stress. This compensatory reduction was lost at the time of the second, "preterminal" scan.     

Multiple focal extraovarian serous carcinoma; three case reports

Three patients with multiple focal extraovarian serous carcinoma are discussed. The disease is characterized by carcinomatosis peritonei of papillary adenocarcinoma type without an evident primary tumor. The clinical aspect is that of ovarian carcinoma. It is proposed that these tumors might originate from the extragenital Müllerian epithelium.     

狼疮肾炎患者妊娠结局分析

目的 探讨系统性红斑狼疮(systemic lupus erythematosus,SLE)合并狼疮肾炎(lupus nephritis,LN)患者妊娠的母婴不良结局及危险因素.方法 对北京协和医院1 990年1月1日至2012年12月31日期间收治的93例LN患者共97例次妊娠进行回顾性分析.根据LN发病时间和病情程度分为3组:妊娠前疾病稳定组(52例次)、妊娠前疾病活动组(26例次)和妊娠期新确诊LN组(19例次).孕产妇不良结局包括妊娠期疾病加重、子痫前期、妊娠期或产后尿蛋白加重、妊娠期或产后肾功能损伤加重、孕产妇死亡、低血小板血症和低补体血症.胎儿或新生儿不良结局包括治疗性终止妊娠(因孕妇疾病加重需要终止妊娠)、胎儿丢失、新生儿死亡、早产、小于胎龄儿和新生儿窒息.组间率的比较采用x2检验和Fisher精确概率法,母婴不良结局的危险因素采用二项分类Logistic回归分析.结果 (1)孕产妇不良妊娠结局:妊娠前稳定组与活动组比较,在妊娠期疾病加重的比例差异无统计学意义[53.8％(28/52)与61.5％(16/26),x2=0.417,P＞0.05].除外妊娠20周前流产的病例(稳定组和活动组分别为5例次和4例次),2组子痫前期发生率差异也无统计学意义[36.2％(17/47)与59.1％(13/22),x2=3.204,P＞0.05].19例次妊娠期新确诊LN患者中,18例次妊娠≥20周,其中子痫前期发生率为6/18.(2)胎儿或新生儿不良结局:妊娠前疾病活动组治疗性终止妊娠的比例高于稳定组[42.3％ (10/26)与7.7％ (4/52),Fisher精确概率法,P＜0.01],差异有统计学意义.除外主动要求终止妊娠(稳定组3例次)和治疗性终止妊娠(稳定组4例次,活动组10例次)的病例,稳定组与活动组分别为45例次与16例次,活动组胎儿丢失和新生儿死亡的比例高于稳定组[5/16与6.7％(3/45),Fisher精确概率法,P＜0.05],差异有统计学意义.妊娠前活动组胎儿或新生儿不良结局发生率高于稳定组[92.3％ (24/26)与50.0％ (26/52),x2=13.483,P＜0.001],差异有统计学意义.19例次妊娠期新确诊LN组的患者中,治疗性终止妊娠5例次,胎儿丢失3例次,活产11例次,新生儿重度窒息并死亡2例次,早产9例次.(3)母婴不良结局危险因素Logistic回归分析:妊娠期疾病加重的独立危险因素为低补体血症(OR=0.300,95％CI:0.104～0.863)和低血小板血症(OR=0.054,95％CI:0.007～0.439);LN孕妇发生子痫前期的独立危险因素为低血小板血症(OR=0.151,95％ CI∶0.046～0.499)和妊娠期LN复发或新发(OR=0.135,95 ％CI∶0.027～0.679);胎儿或新生儿不良结局的独立危险因素为孕妇发生子痫前期(OR=0.134,95％CI:0.028～0.637)和妊娠期疾病活动(OR=0.026,95 ％CI:0.005～～0.138).结论 LN患者妊娠前疾病活动增加胎儿或新生儿不良结局的风险.建议LN患者疾病稳定至少6个月以上再计划妊娠,妊娠期间应密切监测血压、肾功能、尿蛋白、血小板和补体水平等指标,及早发现疾病活动并及时治疗.     

Transabdominal cerclage in the management of cervical pregnancy: three case reports

We report three cases of cervical pregnancy, managed by transabdominal uterine cerclage and cervical curettage: each one was followed by a successful pregnangy. A review of the literature is presented. Correspondence to: G. Loverro     

Maternal, fetal, and newborn complications associated with newborn intracranial hemorrhage

Two hundred twenty newborn infants with one or more fetal or newborn complications and 54 newborn infants without fetal or newborn complications were prospectively studied to assess the relationship between maternal, obstetric, fetal, and newborn complications and intracranial hemorrhage. Intracranial hemorrhage occurred in 47 newborn infants with fetal or newborn complications (21%) and in one infant with no fetal or newborn complications (2%). Maternal and obstetric complications, duration of labor, and mode of delivery were not associated with intracranial hemorrhage. Newborn immaturity at delivery is an important factor in the occurrence of intracranial hemorrhage. There is little evidence that fetal hypoxia is a contributing factor. Severe respiratory complications and major infections are newborn complications associated with intracranial hemorrhage.     

Neonatal necrotizing tracheobronchitis: three case reports.

Necrotizing tracheobronchitis is a serious affection observed in ventilated newborns, frequently infants with instable hemodynamic state. It is characterized by acute episodes of airway obstruction. The treatment consists of the desobstruction by rigid bronchoscopy. The vascular theory seems to be of utmost importance in the physiopathology. Three cases are reported.     

The thromboelastogram and circulating lupus anticoagulant

Abnormal lupus anticoagulant (LA) levels, as measured with the activated partial tissue thromboplastin and tissue thromboplastin inhibition tests, are associated with a predisposition toward thromboembolic phenomena. Thromboelastogram (TEG) measurements have been proposed as a standardized assay to predict such a predisposition. We therefore correlated LA and TEG assessments in 46 women who were either apparently healthy controls or who had abnormal LA levels with such conditions as endometriosis and repeated pregnancy wastage. The coefficient of correlation (Rho) was .3282 (P = .025). Seven patients with an abnormal LA demonstrated a normal TEG, and eight with a normal LA exhibited an abnormal TEG. Only nine had concomitant LA and TEG abnormalities. We conclude that LA and TEG apparently are not interchangeable as predictors of a hypercoagulable state. While this study did not address which of the two assays has a better predictive value for thromboembolic phenomena, it suggested that each can identify a different patient population.     

Maternal and fetal infection

Although their incidence varies among populations, maternal-fetal infections are increasingly recognized to be among the most common causes of maternal and perinatal morbidity. The use of new techniques, including nucleic acid hybridization and direct fetal or trophoblastic cell sampling, continues to accelerate our knowledge of the epidemiology, microbiology, and immunology, as well as means to diagnose, treat, and prevent individual congenitally transmitted infections. Given the number and complexity of these infections, only selected aspects of recent advances are presented.     

Partial placenta increta and methotrexate therapy: three case reports

The term placenta accreta is used to describe any placental implantation in which there is abnormally firm adherence to the uterine wall. This condition complicates 1/2,500 deliveries and is rising in incidence. Abnormal placentation is associated with increased maternal morbidity and mortality from severe hemorrhage, uterine perforation, infection and loss of fertility. The reported experience of methotrexate treatment in the conservative management of placenta accreta is scant. Three cases of partial placenta increta managed with methotrexate are described. The patients were assessed with clinical surveillance, serum beta human chorionic gonadotrophin (beta-hCG) and imaging (ultrasonography and magnetic resonance in one case). In all cases conservative management with methotrexate resulted in undetectable serum beta-hCG, a decrease in the size of partial placenta retained, and undetectable vascularization.     

Placenta accreta and methotrexate therapy: three case reports.

Placenta accreta is a complication that is rising in incidence. The reported experience of methotrexate treatment in the conservative management of placenta accreta is scant. Three cases of placenta accreta managed with methotrexate are presented. Case 1: A woman had an antenatal diagnosis of placenta percreta. A successful manual placental removal occurred on post-cesarean day 16. Case 2: A woman had retention of a placenta accreta after a term vaginal delivery. Successful dilation and curettage were performed on postpartum day 37. Case 3: A woman had an antenatal diagnosis of placenta previa-percreta with bladder invasion. A simple hysterectomy was performed on post-cesarean day 46. Conservative management and methotrexate treatment resulted in uterine preservation in two of our three patients; however, this treatment did not prevent significant delayed hemorrhage. In view of the rapid resolution of vascular invasion of the bladder, methotrexate may have an important role in the management of placenta percreta with bladder invasion. The utility of methotrexate treatment with the conservative management of placenta accreta requires further evaluation.     

Maternal Addison's disease and fetal growth retardation. A case report

Maternal Addison's disease (primary hypoadrenalism) is an infrequent complication of pregnancy that poses a high risk of maternal mortality if not recognized and treated. If adequate steroid replacement therapy is provided, however, there is little risk for the mother during pregnancy. We treated a woman for previously undiagnosed Addison's disease during pregnancy that apparently interfered with normal fetal growth. This case supports Osler's observation that maternal Addison's disease can cause intrauterine fetal growth retardation.     

Lupus anticoagulant: a unique case with lupus anticoagulant and habitual abortion together with antifactor II antibody and bleeding tendency

Lupus anticoagulants (LA) are associated with various forms of thrombotic events. Of particular interest to obstetrics is the association with placental infarcts and habitual abortion. In the case described a near full-term viable infant was delivered subsequent to four early miscarriages. However, the mother had then developed an antifactor II antibody leading to grave hypoprothrombinemia with bleeding tendency, indicating efficient autoanticoagulation. This natural experiment indicates that these patients should receive anticoagulation during pregnancy, possibly in combination with steroids to depress the LA level.