Middle cerebral artery-peak systolic velocity in dizygotic twins with anti-E alloimmunization

Middle cerebral artery-peak systolic velocity (MCA-PSV) has been reported to predict fetal anemia with similar accuracy as amniotic ΔOD450 assay. Alloimmunized dizygotic twin pregnancy allows us to compare anemic and non-anemic twins in the same intrauterine environment. We herein present a case of Rh (E)-incompatible dizygotic twin pregnancy, where MCA-PSV could precisely detect the anemia in one of the twins. A 36-year-old woman, whose previous child required exchange transfusion due to hemolytic anemia of newborn (HFDN), conceived twins after in vitro fertilization-embryo transfer. At 24 weeks' gestation, MCA-PSV of twin A and twin B were 23.9 cm/s (0.8 multiples of median; MoM) and 30.7 cm/s (1.0 MoM), respectively. At 31 weeks' gestation, MCA-PSV values of both twins were sharply elevated to nearly 1.4 MoM. Thereafter, MCA-PSV of twin A fell to 1.0 MoM, whereas MCA-PSV of twin B exceeded 1.5 MoM at 34 weeks' gestation. Development of fetal anemia was suspected and emergency cesarean section was performed. Twin B showed moderate anemia with positive direct Coombs' test and was diagnosed as HFDN due to anti-E alloimmunization. Twin B required phototherapy and red cell transfusion, but exchange transfusion was safely obviated.     

Successful ultrasound-guided intravascular transfusion in severe fetal anemia without blood group incompability

A 26-year-old patient with chronic acquired pure red cell aplasia had given birth to two infants, both of which died from fetal hydrops and anemia. In her third pregnancy the fetus was diagnosed as being hydropic and anemic in the 24th gestational week. No blood group incompability could be demonstrated. Because of the low gestational age and presence of fetal ascites, intraperitoneal fetal blood transfusion was considered to be without effect, and three fetal intravascular transfusions were therefore performed in the 24th, 26th and 28th gestational weeks. The infant born in the 30th week, is in good health with a normal blood picture, 6 months later. Hydrops and fetal anemia has never been described as a complication of pregnancy in a patient with pure red cell aplasia and it is the first time that intrauterine intravascular fetal transfusion has been used other than for rhesus indication.     

Acute myelogenous leukemia mimicking a hemolysis, elevated liver enzymes, and low platelets syndrome during pregnancy: case report and review of the literature

Acute leukemia is a rare malignancy of pregnancy. When it develops, there are many complications to consider and management becomes exceedingly difficult. We report a case of acute myelogenous leukemia presenting as preeclampsia and fetal demise at 36 weeks of gestation. A 30-year-old multigravida presented with intrauterine fetal demise at 36 weeks' gestation, hypertension, and thrombocytopenia. The patient received platelet and packed red blood cell transfusion, with concurrent prophylactic magnesium sulfate and dexamethasone treatment. Following labor induction, the patient delivered a nonviable female fetus and suffered a stroke postpartum. Peripheral smear and flow cytometry revealed the patient had acute myeloid leukemia with prominent monocytic differentiation. The patient expired on postpartum day six. Acute leukemia during the pregnancy is associated with an unfavorable outcome.     

Pregnancy-Associated Parvovirus B19 Infection Causing Postinfectious Glomerulonephritis

Background. Postinfectious glomerulonephritis due to parvovirus B19 during pregnancy is not described in the literature. Objective. A case and renal biopsy of postinfectious glomerulonephritis due to parvovirus B19 during pregnancy is presented. Discussion and Conclusions. The patient contracted “fifth disease,” parvovirus B19, in the 10th week of pregnancy, and 2 weeks later developed hypertension, nephrotic range proteinuria, pleural effusions, and evidence of pure red cell aplasia. Serum parvovirus B19 IgM was positive; a renal biopsy was performed, revealing diffuse proliferative glomerulonephritis with immunofluorescent and electron microscopic changes consistent with postinfectious glomerulonephritis. Renal, hemodynamical, and hematological parameters returned to normal by the 16th week gestation, and the pregnancy proceeded without further complication to the mother, with term delivery of a healthy infant.     

Successful management of pregnancy-associated thrombotic thrombocytopenic purpura by monitoring ADAMTS13 activity

Thrombotic thrombocytopenic purpura (TTP) during pregnancy is very rare and is caused by an absent or severely depleted ADAMTS13 (a disintegrin-like and metallopeptidase with thrombospondin type 1 motif, 13). A 37-year-old multigravida woman developed TTP with severe anemia and thrombocytopenia at 22 weeks' gestation. ADAMTS13 activity was markedly decreased to 3% and ADAMTS13 inhibitor was positive, leading to a definitive diagnosis of TTP. She was successfully treated by plasmapheresis six times, resulting in symptomatic relief. Close follow up with periodic ADAMTS13 measurement facilitated plasmapheresis at appropriate points at a minimum frequency during pregnancy. Because of intrauterine growth retardation from 28 weeks' gestation, an elective cesarean section was performed at 30 weeks' gestation. After delivery, the mother and child showed no appreciable problem. To our knowledge, this is the first report of successful management for pregnancy-associated TTP by monitoring ADAMTS13 activity during pregnancy and the postpartum period.     

Isolation of cytomegalovirus from the amniotic fluid during the third trimester

A case is presented in which cytomegalovirus was isolated from the amniotic fluid at 36 weeks' gestation in a pregnancy complicated by cytomegalovirus hepatitis at 10 weeks of gestation. Abnormalities noted in the newborn infant included an undescended testis, right equinovarus, and hypotonia. All cultures revealed cytomegalovirus. Subsequent immunoglobulin studies, chest x-ray film, and bone films were all normal.     

Polyhydramnios as a sole ultrasonographic finding for detecting fetal hemolytic anemia caused by anti-c alloimmunization

ObjectiveThe prenatal course of a rare case with fetal anemia caused by maternal anti-c alloimmunization was reported.Case reportA 39-year-old female with anti-c and anti-E antibodies against red cells had previously experienced a stillbirth. At her present pregnancy, titers of maternal antibodies and fetal middle cerebral artery peak systolic velocity (MCA-PSV) were frequently monitored to investigate the severity of fetal hemolytic anemia. Rather than manifesting as an increase in MCA-PSV, the anemic fetus was delivered at 32 weeks and one day of gestation with a sole presentation: polyhydramnios. Neonatal hospitalization course were compatible with hemolytic anemia. The baby was discharged at 48 days of age.ConclusionThis case illustrated the complexities of dealing with maternal red cell alloimmunization during pregnancy and the limitations of noninvasive diagnostic modalities for detecting fetal anemia, and highlighted that obstetricians should refer all available clinical parameters in order to offer appropriate perinatal care.     

Erythroblastosis and reticulocytosis in anemic fetuses

The fetal blood erythroblast and reticulocyte counts were determined in umbilical cord samples obtained at 17 to 36 weeks' gestation from 127 pregnancies complicated by red blood cell isoimmunization. The reticulocyte count increased linearly with fetal anemia, and the erythroblast count increased exponentially. Significant erythroblastosis was observed only when the hemoglobin concentration deficit was greater than 7 gm/dl. Of the 52 fetuses with a hemoglobin concentration deficit greater than 7 gm/dl, 35 had ultrasonographic evidence of hydrops. These data suggest that medullary hematopoiesis is stimulated by mild anemia and that recruitment of extramedullary sites occurs when anemia is severe. Extensive hepatic erythropoiesis may be the cause of fetal hydrops in red blood cell isoimmunization.     

Intensive plasma exchange as an adjunct to management of severe rhesus disease

Large-volume plasma exchange was used to reduce the maternal anti-D concentration in a case of severe rhesus disease. The treatment commenced at 19 weeks' gestation and continued until the infant was successfully delivered at 35.2 weeks' gestation. The initial anti-D level of 30 IU/ml was lowered to 10 and was maintained below that level, with few exceptions throughout the program. The volume of plasma exchanged each week varied between 6.8 and 13.4 liters, a total of 154 l. Three IUTs were accomplished, starting from 31 weeks' gestation. The patient's OD values remained far below those recorded in her previous pregnancy which terminated in neonatal death. The replacement fluids consisted of 98 l PPS with FFP added to equilibrate the patient at the end of each procedure, altogether 33 l. At 33 weeks' gestation she developed a transient non-A, non-B hepatitis probably caused by the use of FFP. However, she later made a complete recovery. Large-volume plasma exchanges commenced early in high-risk pregnancy must be individually designed and based on the kinetics of anti-D production. The replacement fluids should preferably consist of pasteurized albumin solutions and intravenous immune globulin.     

Gestational diabetes and maternal third-trimester blood count

OBJECTIVE: To examine the effect of gestational diabetes mellitus (GDM) in the third trimester on the maternal blood count in nonanemic women with singleton pregnancies. STUDY DESIGN: In a prospective, observational study, consecutive women without preexisting anemia or hemoglobinopathies, endocrine disorders or diabetes were recruited for blood sampling for complete blood count at 28-30 weeks' gestation, when they were screened for GDM, and again at 36-38 weeks' gestation. The management of pregnancy or GDM was not influenced by the study. After delivery, the blood count results were compared between women with and without GDM. RESULTS: Of the 462 women recruited, 64 (13.8%) were diagnosed with GDM. This group had similar blood counts at 28-30 weeks but significantly higher hemoglobin, red cell count and hematocrit and lower white cell count at 36-38 weeks as compared with the controls. Except for the lower platelet count, these differences appeared to represent an accentuation of the gestation-related changes that were found in the controls. CONCLUSION: The development of GDM in the third trimester is associated with significant changes in blood counts beyond the effect of advancing gestation alone, probably related to the pathologic effect of diabetes.     

Spontaneous rupture of a utero-ovarian vein during pregnancy

Atraumatic rupture of a utero-ovarian vein during pregnancy is a potentially lethal complication that is likely to be misdiagnosed because of its rarity. We report the case of a 31-year-old woman at 25 weeks' gestation who had an acute abdomen and shock.     

Multi-system cytomegalovirus fetopathy by recurrent infection in a pregnant woman with hepatitis B

A pregnant woman with acute hepatitis B virus (HBV) infection had her second pregnancy terminated at 25 weeks' gestation because of fetal ascites and ventriculitis. Meconium peritonitis was also found at autopsy. No HBV DNA but cytomegalovirus (CMV) DNA was detected in the fetal liver and ascitic fluid. Recurrent maternal CMV infection was demonstrated by pre-existing CMV IgG antibodies, high IgG avidity and low IgM levels. After abortion, the patient developed chronic active hepatitis. Nevertheless, having become pregnant again with a new partner, she had an uneventful third pregnancy and gave birth to a healthy boy.     

Tuberculous peritonitis in pregnancy

Tuberculous peritonitis in pregnancy is one of the least common forms of extrapulmonary tuberculosis in pregnancy. The case is described herein of a 23-year-old primigravida woman with primary tuberculous peritonitis in pregnancy at 24 weeks' gestation. Excisional biopsy taken from the peritoneum during laparotomy resulted in the histopathologic diagnosis of tuberculous peritonitis. The patient made a good physical recovery after being placed on antituberculous chemotherapy and gave birth to a healthy male neonate of 2.5 kg at 37 weeks' gestation by vaginal delivery.     

Congenital factor XIII deficiency with treatment of factor XIII concentrate and normal vaginal delivery

The outcome of all pregnancies complicated by congenital factor XIII (F XIII) deficiency has resulted in abortion without replacement therapy. We experienced a case with this disease and succeeded in normal vaginal delivery after treatment with weekly F XIII concentrate (Fibrogammin P, Behringwerke AG) during pregnancy. This 20-year-old woman, gravida 1, para 0, was found to have an F XIII level of 0% at age 6 and was treated with F XIII concentrate occasionally when she suffered from massive bleeding. In 1986 she became pregnant and was hospitalized at 6 weeks' gestation because of genital bleeding. Subsequent to this episode, F XIII concentrate was administered every week. At 37 weeks' gestation a 2,646-gram girl with a 1-min Apgar score of 9 was delivered. Postpartum blood loss was 260 ml. One year after delivery neither the mother nor the infant were found to have hepatitis B, nonA, nonB hepatitis, ATL or HIV. F XIII concentrate proved effective in such cases without any risk of viral infection.     

Chronic myelocytic leukemia in pregnancy: a case report describing successful treatment using multimodal therapy

Leukemia during pregnancy is rare, posing a complex series of questions, including appropriate therapy and maternal counseling. Management of chronic myelocytic leukemia (CML) during pregnancy is limited. Our patient presented at 30?weeks' gestation with anemia, leukocytosis, and a non-productive cough. Polymerase chain reaction performed on a peripheral blood sample confirmed presence of the breakpoint cluster region-Abl1 chromosomal translocation and the diagnosis of CML. Therapy included acute leukocytapheresis, followed by α-interferon and imatinib mesylate. The patient responded to treatment and delivered a viable female infant at term weighing 2613?g. Continued imatinib mesylate chemotherapy post-delivery resulted in complete clinical remission. Successful antepartum management of newly diagnosed CML is possible utilizing leukocytapheresis, α-interferon and, more recently, imatinib mesylate. Definitive treatment should not be delayed due to pregnancy.     

Pancreaticoduodenectomy as treatment of adenocarcinoma of the papilla of Vater diagnosed during pregnancy. A case report.

BACKGROUND: Papillary adenocarcinomas are rare tumors of the gastrointestinal tract. There are few reports of this neoplasm diagnosed during pregnancy. CASE: A case of adenocarcinoma of the papilla of Vater was diagnosed by sonographically guided biopsy during pregnancy. The patient underwent radical resection of the tumor at 25 weeks' gestation; pregnancy termination was not indicated. At 39 weeks' gestation, a cesarean-section was performed. The postoperative period entailed total parenteral nutrition until intestinal motility stabilized. This ensured the mother and fetus' well-being until delivery. CONCLUSION: Papillary adenocarcinoma is associated with good prognosis since it is totally removed by radical resection, and pancreaticoduodenectomy can be performed successfully during pregnancy, but the patient must receive special prenatal care.     

Fetal plasma erythropoietin concentration in red blood cell-isoimmunized pregnancies.

OBJECTIVE: The aim of this study was to investigate the relationship between fetal anemia, plasma erythropoietin concentration, and erythroblastosis in red blood cell-isoimmunized pregnancies. STUDY DESIGN: Fetal plasma erythropoietin concentration in umbilical venous blood samples from 68 red blood cell-isoimmunized pregnancies at 18 to 35 weeks' gestation was measured. Measurements were compared with the appropriate reference range with gestation, and associations with blood pH, erythroblast count, and hemoglobin concentration were examined. RESULTS: The mean fetal plasma erythropoietin concentration and erythroblast count in red blood cell-isoimmunized pregnancies were significantly increased only in severe fetal anemia (hemoglobin deficit > 7 gm/dl). Furthermore, some severely anemic fetuses were hydropic and acidemic. The degree of increase in plasma erythropoietin was significantly associated with both fetal acidemia and, more strongly, fetal erythroblastosis. CONCLUSION: These findings suggest that in fetuses from red blood cell-isoimmunized pregnancies the ability to prevent tissue hypoxia is present until anemia becomes severe, presumably by an increase in cardiac output and tissue perfusion. In severe anemia tissue hypoxia occurs, and the data indicate that fetuses respond by increasing erythropoietin production from at least 20 weeks' gestation. Furthermore, more accurate assessment of tissue oxygenation may be obtained by measuring the erythroblast count rather than the blood pH.     

Rupture of a rudimentary horn pregnancy with a combined intrauterine pregnancy. A case report.

In the first reported case of a rudimentary horn pregnancy coexistent with an intrauterine pregnancy, the patient presented at 19 weeks' gestation with acute abdominal distress. A ruptured left rudimentary horn pregnancy was found at laparotomy. The rupture was repaired. Preterm labor ensued 24 hours later, with resultant delivery of the second twin from the right cornu despite aggressive tocolysis.     

Prolonged, pregnancy-related pure red cell aplasia; a case report.

We describe the clinical course of a patient with pregnancy-related, acquired, pure red cell aplasia (PRCA). The course of PRCA was prolonged and ultimately responded only to corticosteroids. It did not recurr over 4 years of observation despite another gestation, and no other cause for PRCA could be detected during this long period.     

Oligohydramnios and pulmonary hypoplasia: a case in which involvement of an angiotensin II receptor antagonist was suspected

Administration of an angiotensin II receptor antagonist (ARB) during the second trimester of pregnancy is known to cause irreversible renal damage in the fetus. We report a case in which ARB was given to the mother from the first trimester until 26 weeks' gestation. The patient had diabetic nephropathy with accompanying nephrotic syndrome. At 8 weeks' gestation, she was started on candesartan cilexetil (an ARB). At 26 weeks' gestation, she was transferred to our center. Severe oligohydramnios was noted. The pregnancy was terminated, and she delivered at 27 weeks' gestation. The neonate weighed 884 g and died 1 h after birth. Autopsy revealed that the lung/bodyweight ratio was 0.0096 (>0.015) and pulmonary hypoplasia was noted. Histological examination of the kidneys showed tubular dysgenesis with poor differentiation of the proximal tubules.