Cervical cerclage: twenty years' experience.

During a 20-year period, 40 pregnancies were managed in 32 patients with a diagnosis of an incompetent cervix, a ratio of 1:775 deliveries. Diagnosis before development of symptoms produced a 92% fetal salvage, with 68% reaching 36 weeks of gestation. Development of symptoms before cerclage resulted in only a 40% fetal salvage. Fetal salvage was reduced in cases where membranes bulged beyond the cervix, the cervix was more than 3 cm dilated, or the gestational age was greater than 26 weeks at the time of suture placement. No difference was noted between the Shirodkar and McDonald procedures. Major complications included uterine rupture in three patients and acute chorioamnionitis in two. Because of complications, treatment is contraindicated based on history alone or where close follow-up is not available.     

Retrospective analysis of cervical cerclage procedures at the Louisiana State University, Shreveport (1980 to 1987)

We retrospectively reviewed 76 cerclage procedures done in 62 patients from January 1980 through October 1987 at the Louisiana State University Medical Center, Shreveport. The study showed a significant increase in fetal salvage after cerclage--from 23% to 72%. Emergency cerclage resulted in a fetal salvage rate of only 12%, in contrast to elective cerclage, which yielded a fetal salvage of 81%. Furthermore, fetal salvage was lower when the cerclage was done at less than 12 weeks' estimated gestational age (65%). The McDonald cerclage was done in 69 procedures, using a single suture in 49 patients and a double suture in 20. The fetal salvage rate was the same regardless of the number of sutures placed.     

Ultrasound evaluation of sutures following cervical cerclage for incompetent cervix uteri.

This prospective study was designed to determine whether it is possible to visualize cerclage suture material by ultrasound and to evaluate the clinical usefulness of ultrasound examination after cervical cerclage during pregnancy. Ultrasound examinations demonstrated suture material in all patients in this study. The 5-mm-wide Mersiline tape suture, used in the Shirodkar procedure, was easier to visualize by ultrasound than the no. 2 nylon suture used in the McDonald procedure. Ultrasound examination can be helpful in evaluating the location and effectiveness of the sutures and in detecting protrusion of the membranes beyond the sutures before it is clinically apparent. The sonographic demonstration of the relationship of the protruding membranes to the level of the sutures can be valuable in patient management.     

Transabdominal first trimester embryofetoscopy as a potential approach to early in utero stem cell transplantation and gene therapy.

OBJECTIVE: To explore the potential of embryofetoscopy for early diagnosis and for access to the fetal circulation in the first trimester of gestation. DESIGN: Transabdominal embryofetoscopy was performed in 14 patients scheduled for termination of pregnancy using a 1-mm semirigid fibreoptic telescope with a 18 gauge examination sheath and a single-chip digital camera. A 25 gauge needle was inserted through an additional 21 gauge side port to access the fetal circulation. RESULTS: Fetal head, face, abdomen, complete upper and lower limbs could be visualized in over 80% of cases. On the contrary, the fetal back and external genitalia could be examined in detail only in some cases (35.7% and 64.3%, respectively). Injection of 10-20 ml saline improved visibility in 43% of cases. Funipuncture was successful in two of three attempts. CONCLUSIONS: Our experience suggests that embryofetoscopy is a useful tool for early diagnosis in the first trimester of pregnancy. Funipuncture is possible thus providing the means for an early intravascular stem cell application.     

Elective cerclage vs. ultrasound-indicated cerclage in high-risk pregnancies.

OBJECTIVE: To compare pregnancy outcome after elective vs. ultrasound-indicated cervical cerclage in women at high risk of spontaneous mid-trimester loss or early preterm birth. METHODS: This was a retrospective study comparing two management strategies in women with singleton pregnancies who had at least one previous spontaneous delivery at 16-33 weeks of gestation. One group was managed by the placement of an elective cerclage at 12-16 weeks and the other group had transvaginal ultrasound examinations of the cervix at 12-15+6, 16-19+6, and 20-23+6 weeks and cervical cerclage was carried out if the cervical length was 25 mm or less. RESULTS: A total of 90 patients were examined, including 47 that were managed expectantly and 43 treated by elective cerclage. In the expectantly managed group, 59.6% (28/47) required a cervical cerclage. We excluded from further analysis three patients who were lost to follow-up and three because of fetal death or iatrogenic preterm delivery. Miscarriage or spontaneous delivery before 34 weeks' gestation occurred in 14.6% (6/41) of the elective cerclage group, compared with 20.9% (9/43) in the expectantly managed group (chi2 = 0.219, P = 0.640). CONCLUSION: In women at increased risk of spontaneous mid-trimester or early preterm delivery, a policy of sonographic surveillance followed by cervical cerclage in those with a short cervix reduces the need for surgical intervention without significantly increasing adverse pregnancy outcome.     

Successful prenatal and perinatal management of a massive cervicofacial teratoma

We report a fetus with a massive cervicofacial teratoma successfully managed in the prenatal and perinatal period. A 34-year-old woman was referred to our hospital at 16 weeks’ gestation. Ultrasound examination revealed a left anterolateral fetal neck mass indicating typical findings of a teratoma. The tumor grew to tremendous size until occupying most of the uterine cavity causing severe discomfort for the patient. This necessitated ultrasound-guided removal of the intracystic fluid of the massive cervicofacial teratoma during pregnancy. Fetal MRI clearly demonstrated the mass extending from the orbit to the anterior chest wall without compression or deviation of the fetal airway. The entire mass increased to 18 cm in diameter at 37 weeks’ gestation. Classical cesarean section was performed immediately after ultrasound-guided removal of the fluid from the cyst. A female infant weighing 3562 g was delivered. Resection of the tumor was accomplished on day 28 of life. The successful outcome in our case illustrates the value of accurate prenatal diagnosis of a giant cervicofacial teratoma using ultrasound and MRI, and careful management of the mother and fetus during the prenatal and perinatal period. It seems that ultrasound-guided removal of the intracystic fluid from the tumor during pregnancy should be considered to prevent preterm delivery.     

Computer analysis of three-dimensional power angiography images of foetal cerebral, lung and placental circulation in normal and high-risk pregnancy

Three-dimensional (3-D) ultrasound (US) has greatly improved evaluation of organ circulation. The aim of this study was to explore the possible use of this new technique in normal and high-risk pregnancies. Fetal brain, lung and placenta 3-D power Doppler signal intensity were recorded in 115 normal singleton pregnancies (24 to 42 weeks gestation) and in 67 high-risk pregnancies. Mean image pixel signal intensity was calculated for each organ and a brain-lung ratio. In normal pregnancy, placental and lung signal intensity increased until 33, with a rapid decrease after 38, weeks of gestation. Fetal cerebral signal intensity increased with gestational age. Placental and fetal lung signal intensity was significantly lower in high-risk pregnancies than in the control group, with increased fetal brain and brain-lung ratios. The present results suggest a reduction of placental perfusion after 38 weeks of gestation in normal pregnancy, with redistribution of fetal circulation. Lung signal intensity increased abruptly at 32 weeks of gestation, which might reflect lung maturity. The new method showed signs of centralization of fetal circulation at the end of gestation. The results might suggest a possible clinical use for fetal surveillance in high-risk pregnancies.     

Cervical incompetence: the use of transvaginal sonography to provide an objective diagnosis.

OBJECTIVE: To investigate the use of transvaginal sonography in monitoring the cervix in women at high risk of a preterm delivery. STUDY DESIGN: One hundred and six women at high risk of preterm labor had regular cervical monitoring by transvaginal ultrasound throughout pregnancy from the second trimester to delivery. The study was designed to be observational, but intervention was considered if the cervical length fell below 10 mm. RESULTS: Eleven women demonstrated opening of the cervical canal at rest or with fundal pressure before 24 weeks' gestation. Between 2 and 17 days later all 11 cervices progressively shortened to a cervical length of < 10 mm. Nine women had a cervical cerclage. Seven women had fetal membranes visible within the cervical canal at the time of cerclage. One woman miscarried at 18 weeks, and the other 10 had live births at a median gestational age of 36 (range, 27-38) weeks. CONCLUSIONS: Cervical length shortening in the second trimester, once started, progressed to a cervical length under 10 mm. Opening of the cervical os at rest or in response to fundal pressure detected by transvaginal ultrasound appears to be the early ultrasound feature of cervical incompetence.     

Primary glomerulonephritis and pregnancy

Three hundred and ninety-five pregnancies undertaken by 238 women with primary glomerulonephritis between 1962 and 1987 were analysed to record fetal and maternal outcome and identify risk factors for a poor outcome. Of 398 fetuses, 26 per cent were lost (including therapeutic abortions), 24 per cent surviving infants were premature (less than or equal to 36 weeks gestation) and 51 per cent were term. Excluding therapeutic abortions, 20 per cent of fetuses were lost, 15 per cent after 20 weeks gestation. Fifteen per cent of 237 fetuses whose birth weight was recorded were small for gestational age: Deterioration in maternal renal function was seen in 15 per cent of pregnancies and in 5 per cent of women failed to resolve post partum. Only four women had impaired renal function recorded in the first-trimester and two of these were known to have renal impairment before pregnancy. Hypertension was recorded in 52 per cent of pregnancies, developed early (less than or equal to 32 weeks gestation) in 26 per cent and was severe in 18 per cent. Treated hypertension pre-dated 12 per cent of pregnancies and in 7 per cent (included in the overall incidence of hypertension) exacerbation occurred during pregnancy despite continued antihypertensive medication. Forty-four women (18 per cent) who developed de novo hypertension in pregnancy had permanent hypertension postpartum. Increased proteinuria was recorded in 59 per cent of pregnancies and was irreversible in 15 per cent of women. Comparison of pregnancies which occurred before or after renal biopsy revealed a significantly higher fetal loss rate after 20 weeks gestation in those pregnancies undertaken before the diagnosis of renal disease, and a significantly higher incidence of hypertension and increased proteinuria. Impaired renal function, early or severe hypertension or nephrotic range proteinuria was significantly associated with increased fetal loss, prematurity and fewer full-term infants. There was no significant difference in fetal outcome or maternal complications in pregnancy in patients with treated hypertension before pregnancy and those who were normotensive in the first-trimester. The highest incidence of fetal and maternal complications occurred in patients with primary focal and segmental hyalinosis and sclerosis and the lowest in non-IgA diffuse mesangial proliferative glomerulonephritis. The presence of severe vessel lesions on renal biopsy was associated with a significantly higher total fetal loss and fetal loss after 20 weeks gestation.     

Relation between fetal blood gas levels and the outcome of babies in severe preeclampsia.

The purpose of this study is to ascertain that fetal blood gas values obtained by cordocentesis could be a clinical standard to decide whether or not we should terminate pregnancy and switch to exutero salvage for avoiding hypoxic damage. Fetal blood sampling was performed 38 times in 36 cases of severe preeclampsia. The relation between fetal blood gas values and the prognosis of the baby was statistically examined. Six of 36 fetuses of severe preeclampsia died prenatally or postnatally. There were significant differences in delta-values (difference from the normal mean value in each gestational week) of pO2, pCO2, and pH between survivors and non-survivors. delta pO2 value is most reliable to predict fetal prognosis. Since conventional fetal evaluation methods such as fetal heart rate monitoring are unreliable in the early gestational period, fetal gas evaluation is preferable to decide further intervention.     

宫颈环扎术治疗宫颈机能不全的临床研究

目的：探讨宫颈环扎术治疗宫颈机能不全的疗效。方法：分析1996年1月—2009年12月79例因宫颈机能不全行宫颈环扎术患者的临床资料。结果：（1）79例宫颈机能不全患者中76例获得活婴,3例失败,手术总成功率为96.20%。其中26例行选择性宫颈环扎术,成功25例,失败1例。44例行治疗性宫颈环扎术,无一例失败。9例行急诊宫颈环扎术,成功7例,失败2例,成功率为77.78%,明显低于非急诊宫颈环扎术的成功率（96.15%）。（2）与孕20周后相比,孕20周前行选择性环扎术者妊娠天数和新生儿出生体质量明显增加（261.83±9.89d比243.64±26.04d;3106.67±423.14g比2550.36±792.68g）。（3）在治疗性宫颈环扎组和选择性环扎术组中,有3次以上流产史者宫颈环扎后分娩时妊娠天数和新生儿出生体质量明显高于流产次数少于3次者（261.50±10.97d比237.10±27.05d;3025.00±524.81g比2458.50±818.63g）。结论：宫颈环扎术治疗宫颈机能不全疗效肯定;急诊宫颈环扎术是可行的,它可以明显改善宫颈机能不全患者的预后;在孕20周前行选择性环扎术可以明显增长分娩孕周和增加新生儿出生体质量;无论是选择性还是治疗性宫颈环扎,流产3次以上的患者更能从手术中获益。     

Successful intrauterine treatment with radiofrequency ablation in a case of acardiac twin pregnancy complicated with a hydropic pump twin.

Twin reversed arterial perfusion sequence is a serious complication of monochorionic twin pregnancy, as the pump twin that perfuses blood to the acardiac twin may experience heart failure and fetal hydrops resulting in a poor perinatal outcome. A woman with an acardiac twin pregnancy complicated by a hydropic pump twin underwent intrauterine treatment with radiofrequency ablation (RFA) at 27 weeks of gestation. Obliteration of blood flow to the acardiac twin from the pump twin was successful. Fetal hydrops resolved by the time of delivery at 32 weeks of gestation, in spite of transient deterioration, and a good postnatal outcome was achieved for the pump twin. We found that RFA was an effective intrauterine treatment for acardiac twin pregnancy and suggest that it could be introduced in cases complicated by a hydropic pump twin.     

Sonographic diagnosis of a viable abdominal pregnancy with planned delivery after fetal lung maturation

We report a case of a viable abdominal pregnancy with successful outpatient management until fetal lung maturation and planned delivery. Advanced abdominal pregnancy is a very rare extrauterine pregnancy, which results in serious maternal and fetal morbidity. A 28‐year‐old nullipara was referred from the local clinic to our tertiary center at 18 weeks' gestation. We diagnosed an extrauterine fetus on sonographic examination. The patient had weekly antenatal sonographic examinations. We performed a planned laparotomy at 34 weeks' gestation, and a female baby weighing 2,100 g was delivered. The placenta was completely removed and the uterus was preserved. Both the mother and the baby had no postoperative morbidity. © 2012 Wiley Periodicals, Inc. J Clin Ultrasound 41 :563–565, 2013.     

Cervical Incompetence Prevention Randomized Cerclage Trial (CIPRACT): effect of therapeutic cerclage with bed rest vs. bed rest only on cervical length.

OBJECTIVE: To compare the effects of therapeutic cerclage and bed rest vs. just bed rest on cervical length and to relate these effects to the risk of preterm delivery. DESIGN: Cervical length was measured in patients at high risk of cervical incompetence. When a cervical length < 25 mm was measured before 27 weeks' gestation, randomization for therapeutic cerclage and bed rest vs. just bed rest was performed. After randomization, cervical length was measured weekly. For statistical analysis, t-test and Fisher's exact tests were used and P < 0.05 was considered statistically significant. RESULTS: Nineteen women were randomly allocated to receive a therapeutic cerclage and bed rest and 16 were allocated to receive bed rest only. Mean cervical lengths and mean gestational ages before randomization were comparable between both groups, overall 19.8 mm and 20.7 weeks. Cervical length was measured again at a mean gestation of 22.1 weeks. Mean cervical length (31 mm) was significantly (P < 0.0001) longer after cerclage than after bed rest only (19 mm). A cervical length > or = 25 mm was measured in 22 of the 35 included women, 16 in the cerclage group and six in the bed-rest group (P = 0.006). Of these 22 women, only one delivered before 34 weeks' gestation, which was significantly less frequent than six out of 13 women with a cervical length < 25 mm (P = 0.006). CONCLUSIONS: Therapeutic cerclage with bed rest increases cervical length more often than bed rest alone. A postintervention cervical length > or = 25 mm reduces the risk of preterm delivery in women at high risk of cervical incompetence and a preintervention cervical length < 25 mm.     

Diagnosis of congenital cardiac defects between 11 and 14 weeks' gestation in high-risk patients.

OBJECTIVE: To examine the feasibility of diagnosing congenital cardiac defects between 11 and 14 weeks' gestation in a high-risk population. METHODS: Fetal echocardiography was first offered at 11 to 14 weeks' gestation to all patients at risk for congenital heart defects. Echocardiography performed at 11 to 14 weeks with normal results was repeated at 14 to 16 and 20 to 24 weeks. Final diagnoses of cardiac anomalies that had been observed at 11 to 14 weeks were established at 14 to 16 weeks or later Fetal echocardiography performed at 14 to 16 weeks with normal results was repeated at 20 to 24 weeks. Ascertainment of cardiac anomalies was obtained by postnatal echocardiography or pathologic examination of the fetal heart after termination of pregnancy. Most of the examinations were performed transvaginally until 16 weeks. The transabdominal approach was used at this stage only when patients refused the transvaginal examination or because of technical difficulties. Three hundred ninety-two fetal echocardiographic examinations were performed between 11 and 14 weeks' gestation; 438 examinations were performed between 14 and 16 weeks; and 777 examinations were performed between 20 and 24 weeks. The major indications for fetal echocardiography at 11 to 14 weeks were maternal diabetes and previous pregnancy with congenital heart defects. RESULTS: Six of 7 major fetal cardiac anomalies were detected. The only major cardiac anomaly that was not detected between 11 and 14 weeks was correctly diagnosed at 22 weeks. Only 1 of 5 minor fetal cardiac anomalies was detected between 11 and 14 weeks. Another 2 minor fetal cardiac anomalies were detected at 23 weeks. Four incorrect diagnoses of minor cardiac anomalies were excluded on repeated fetal echocardiography between 20 and 24 weeks. CONCLUSIONS: The initial attempt to diagnose congenital heart defects should be offered at 11 to 14 weeks' gestation.     

Kinetics of fetal cellular and cell-free DNA in the maternal circulation during and after pregnancy: implications for noninvasive prenatal diagnosis

BACKGROUND: Fetal genetic material is detectable in the maternal circulation and has been used for noninvasive prenatal diagnosis. However, few data are available concerning its quantity and natural history during gestation. STUDY DESIGN AND METHODS: This study prospectively characterized the kinetics of cellular and cell-free fetal DNA in the circulation of 25 healthy women during and after uncomplicated pregnancy. Real-time kinetic PCR was used to quantitate human Y-chromosome sequences, and liquid oligomer hybridization with (32)P-labeled probes was used to verify the identity of amplified products. RESULTS: In all male pregnancies, but no female pregnancies, low-level fetal Y-chromosome DNA was detected in both cellular and cell-free compartments beginning at 7 to 16 weeks but increasing steadily after 24 weeks and reaching a peak at parturition. The fetal DNA decreased rapidly after birth. CONCLUSION: Fetal genetic material can be detected throughout pregnancy, and its quantity is a function of gestational age and of whether the plasma or cellular compartment is examined. Both the absolute quantity of fetal DNA and its ratio to total DNA (maternal + fetal) are greater in the plasma than in the cellular compartment. Fetal DNA is cleared rapidly from both compartments after parturition, which suggests that turnover is dynamic. Because they provide prospective and quantitative data concerning fetal DNA levels, these observations and kinetic PCR methods may have implications for noninvasive prenatal diagnosis. Further studies will be needed to determine the immunologic implications of fetal-maternal DNA exchange and cellular microchimerism.     

Interstitial pregnancy undetected during earlier first-trimester screening for fetal aneuploidy at 13 weeks' gestation

First-trimester screening for fetal aneuploidy using nuchal translucency (NT), pregnancy-associated plasma protein A, free or total beta-hCG, and maternal age constitutes a very effective screening test for fetal Down syndrome. We describe a case in which a patient presented at 14 weeks' gestation with an acute abdomen 1 week after first-trimester screening (including NT measurement) performed elsewhere, which was negative for trisomies 21 and 18. Sonographic examination revealed an interstitial pregnancy with a singleton fetus with present cardiac activity, which had not been noted 1 week earlier at the time of earlier transabdominal NT measurement. This case indicates that successful acquisition of a NT measurement during first-trimester screening for fetal aneuploidy does not negate the rare possibility of an unusual ectopic pregnancy.     

Development of gastric emptying in the human fetus.

OBJECTIVE: To evaluate stomach size and the development of gastric emptying in human fetuses using ultrasound. DESIGN: Clinical observational study. METHODS: The motility and peristalsis of the fetal stomach were studied in 80 normal fetuses between 12 and 39 weeks of gestation. Fetal gastric motility was assessed by analysis of videotaped recordings of ultrasound images of the stomach taken in real time. RESULTS: Fetal maximum gastric area gradually increased and minimum gastric areas gradually decreased after 20 weeks of gestation. At term, the maximum and minimum gastric area ratios were approximately 13 and 5%, respectively. The change in fetal gastric area, defined as the difference of maximum and minimum gastric area ratios, was relatively constant at 3% from 12 to 15 weeks of gestation to 20-23 weeks of gestation. It increased significantly (to 8%) after 24-27 weeks of gestation until term. CONCLUSIONS: Fetal gastric emptying was quantified and its development assessed during pregnancy. A critical point of gastric development, associated with an increase in the change of gastric volume, was identified at 24-25 weeks of gestation.     

A comparison of sonographic cervical parameters in predicting spontaneous preterm birth in high-risk singleton gestations.

OBJECTIVES: To assess the role of cervical sonography and to compare various sonographic cervical parameters in their ability to predict spontaneous preterm birth in high-risk singleton gestations. DESIGN: A prospective cohort of 469 high-risk gestations were longitudinally evaluated between 15 and 24 weeks' gestation on 1265 occasions with transvaginal cervical sonography and transfundal pressure. The cervical parameters obtained were funnel width and length, cervical length, percent funneling and cervical index. The information obtained was used for patient management. Restriction of physical activities was initiated at cervical lengths of < or = 2.5 cm with cerclage as an option for cervical lengths of < or = 2.0 cm. RESULTS: Receiver operating characteristic curve analyses showed that a cervical length of < or = 2.5 cm between 15 and 24 weeks' gestation was equal to the other sonographic cervical parameters in its ability to predict spontaneous preterm birth. The sensitivities for delivery at < 28, < 30, < 32 and < 34 weeks' gestation were 94%, 91%, 83% and 76%, respectively, while the negative predictive values were 99%, 99%, 98% and 96%, respectively. The placement of a cerclage did not influence the positive and negative predictive values. In comparison to women with other risk factors, cervical length was best in the prediction of preterm birth in women with a prior mid-trimester loss; an optimal cut-off of < or = 1.5 cm had sensitivities for delivery at < 28, < 30, < 32 and < 34 weeks' gestation of 100%, 100% 92% and 81%, respectively. The rate of preterm delivery at < 34 weeks' gestation increased dramatically when the cervical length was < or = 1.5 cm. Cervical length was the only independent variable that entered the logistic regression model for the prediction of preterm delivery at < 34 weeks' gestation. CONCLUSIONS: In high-risk singleton gestations a cervical length of < or = 2.5 cm was equal to other sonographic cervical parameters in its ability to predict spontaneous preterm birth and was better for the prediction of earlier forms of prematurity (at < 28 and < 30 weeks) than later forms (at < 32 and < 34 weeks). The optimal cervical lengths and their performance for predicting prematurity may be influenced by obstetric risk factors.     

Malignant primary hypertension in pregnancy treated with lisinopril

OBJECTIVE: To report a case of a patient treated with an angiotensin-converting enzyme (ACE) inhibitor with a good neonatal outcome. CASE REPORT: A 39-year-old African-Caribbean patient who had chronic hypertension presented at 18 weeks' gestation with acute hypertension. She was being treated for chronic hypertension with lisinopril, but had self-discontinued treatment. Attempts to control her hypertension with labetolol, nifedipine, and methyldopa were ineffective. She was therefore offered termination of pregnancy so treatment with lisinopril could be restarted. The patient elected to continue with the pregnancy in spite of the fetal risks associated with the use of an ACE inhibitor. She was delivered of a girl at 26 weeks' gestation. The baby initially had renal failure and also developed acute necrotizing enterocolitis. The renal failure improved simultaneously with the latter complication, and it is postulated that there was enteric excretion of lisinopril. The baby was discharged home on day 102 with no further complications. DISCUSSION: ACE inhibitors are acceptable medications to use in the first trimester of pregnancy; however, fetal malformations and neonatal complications have been associated with their use later in pregnancy, and they have a perinatal mortality rate of 97/1000. Lisinopril is excreted in urine and feces unchanged, and its half-life is prolonged in anuric neonates. Peritoneal dialysis eliminates lisinopril; however, this neonate improved after treatment for necrotizing enterocolitis and simultaneous improvement in bowel function. CONCLUSIONS: ACE inhibitors should not be used in pregnancy beyond the end of the first trimester. In exceptional cases, they may be indicated for the control of severe hypertension when the patient is refractory to other medications. The patient should be fully counseled about the adverse effect profile and neonatal outcome. This case report documents a successful outcome for mother and baby in these circumstances.