Biomedical subjects
Publications and source records attributed to Michael G Pinette.
Cerebral abscess is an extremely rare complication of pregnancy. We report a case of a patient at 36 weeks of gestation presenting with severe headache, confusion, and seizures after starting treatment for sinusitis. Imaging revealed a left temporal lobe abscess, which was treated with broad-spectrum antibiotics. Neurologic deterioration in a gravida with sinusitis suggests secondary sinogenic intracranial suppurative complications.
Uterine exteriorization during fetal surgery permits hysterotomy away from anterior placental implantations. We employed this technique in two cesarean deliveries for anterior placenta previa-accreta, facilitating selective uterine incisions. Exteriorization of the near-term gravid uterus may be a useful adjunct to cesarean delivery for anterior placenta previa-accreta.
Brain abscess is a potentially life-threatening complication that is only rarely associated with pregnancy. Although predispositions such as a preexisting infection, foreign body, or immunosuppression are often present, up to 30% of individuals could have no risk factors. Presenting symptoms are often nonspecific but suggestive of a central nervous system process and include headache, seizures, mental status changes, and focal neurologic deficits. Cranial imaging by computed tomography (CT) or magnetic resonance imaging (MRI) can suggest the diagnosis of abscess. Diagnosis is confirmed by aspiration of purulent material. Treatment involves antibiotics, often with surgical drainage. Vaginal delivery at term appears to be safe. Care of the affected gravida, including time and route of delivery, should be approached by a team representing perinatology, neurosurgery, infectious disease, and anesthesiology.
UNLABELLED: Primary elective cesarean performed on a patient's request now comprises 4% to 18% of all cesareans and 14% to 22% of elective cesareans in reported series. Patients most commonly choose cesarean because of tocophobia, or fear of childbirth. Almost two thirds of obstetricians surveyed are willing to perform cesarean on request, citing decreased risk of pelvic floor or fetal injury, maintenance of sexual functioning, and physician and patient convenience. Contrasting these beliefs are the limited available data on short- and long-term maternal and perinatal morbidity and mortality that generally favor vaginal delivery. Moreover, comprehensive economic impact assessments of cesarean on request are lacking, and professional organizations do not agree on the ethics of offering patient choice cesarean. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES: After completion of this article, the reader should be able to list the reasons that women and obstetricians choose elective cesarean delivery, to outline the ethical aspects of cesarean delivery, and to describe the material and fetal morbidity and mortality associated with cesarean delivery compared to vaginal delivery.
OBJECTIVE: To determine whether intracardiac echogenic foci (ICEF) are markers of congenital heart disease (CHD) in fetuses with chromosomal abnormalities. METHODS: We identified all fetuses with chromosomal abnormalities undergoing targeted sonography at 17 weeks' to 21 weeks 6 days' gestation in a single perinatal center from January 1, 1994, to June 30, 2003. Offspring with and without CHD were compared for the presence or absence of ICEF. RESULTS: Two (8%) of 25 fetuses with ICEF had CHD versus 38 (33.3%) of 114 fetuses without ICEF (P = .006). Similarly, 1 (5.5%) of 18 fetuses with trisomy 21 and ICEF had CHD compared with 16 (37.2%) of 43 fetuses with trisomy 21 without ICEF (P = .009). CONCLUSIONS: Intracardiac echogenic foci in fetuses with chromosomal abnormalities, including those with trisomy 21, are not useful markers for CHD.
PURPOSE: We screened pregnant women at low risk of a fetal chromosomal abnormality for the presence of fetal intracardiac echogenic foci (ICEF) and graded those foci by using sonographic gain reduction. Our objectives were to determine the interobserver reliability of the technique and the association of ICEF, by grade, with fetal aneuploidy. METHODS: Pregnant women who were 18-35 years old, at low risk for fetal chromosomal abnormalities, and referred for targeted sonography at 16-24 weeks' menstrual age were eligible to participate. All patients whose fetuses had ICEF were offered fetal chromosomal analysis. The presence of ICEF was ascertained by an apical 4-chamber view of the fetal heart and graded independently by 2 examiners blinded to each other's assessment. Grading was based on the difference in echogenicity of the ICEF and the thoracic spine as the ultrasound gain was reduced; in grade 1, the ICEF image was lost before that of the thoracic spine; in grade 2, the ICEF and thoracic spine images disappeared at the same gain setting; and in grade 3, the thoracic spine image was lost before that of the ICEF. RESULTS: During the 6-month study period, 383 eligible women were examined, and ICEF were seen in 35 fetuses (9.1%): 25 (71.4%) in the left ventricle, 1 (2.9%) in the right ventricle, and 9 (25.7%) in both ventricles. ICEF grading was successfully performed in all 33 of the women with fetal ICEF who elected to participate. Twenty-one (63.6%) had grade 1, 9 (27.3%) had grade 2, and 3 (9.1%) had grade 3 ICEF. Interobserver agreement was noted in 27 (90.0%) of 30 available paired second-trimester observations (kappa = 0.8), indicating excellent agreement. Two fetuses (6.1%) with grade 1 ICEF but no other risk factors for aneuploidy had chromosomal abnormalities, as compared with 1 fetus (0.3%) in the control group, which had no ICEF (p = 0.02). CONCLUSIONS: Sonographic grading of ICEF is feasible and reliable. The presence of fetal ICEF in a population otherwise at low risk for aneuploidy seems to warrant the performance of fetal chromosomal analysis.
Partial mole is distinguishable from complete mole with coexisting normal twin after delivery by DNA polymorphysm analysis. Our patient had chorionic villus sampling of a molar-appearing placenta with coexisting fetus at 12.3 weeks. Absent maternal alleles confirmed a diandrogenetic complete mole. Prenatal DNA diagnosis of complete mole is possible and clinically useful.
UNLABELLED: Ileal pouch anal anastomosis is the surgical treatment of choice for ulcerative colitis, offering intestinal continuity and fecal continence. IPAA does not seem to affect menstrual function or gynecologic symptoms. Overall sexual satisfaction may be improved with surgery, although ability to experience orgasm and coital frequency remain essentially unchanged. However, dyspareunia seems to increase postoperatively. Fertility is also adversely affected by IPAA, possibly a result of pelvic adhesions. Pregnancy is characterized by a transient increase in day and night stool frequency and incontinence that resolves after delivery. The ideal route of delivery has not been determined, but vaginal delivery seems safe and does not directly cause pouch dysfunction. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES: After completion of this article, the reader will be able to describe the procedure ileal pouch anal anastomosis, to summarize the effects of IPAA on menstrual function and sexual health, and to outline the association of IPAA and infertility.
The normal fetal lateral ventricular diameter remains stable at 10 mm over gestation. Mild ventriculomegaly, defined as a lateral ventricular diameter of >or=10 mm but or=3 mm but <or=8 mm occurs bilaterally in 0.15-0.7% of fetuses and unilaterally in 0.07% of pregnancies. This finding is associated with an increased risk of fetal chromosomal abnormalities, congenital anomalies and infections, syndromes, perinatal death, and childhood developmental delays. Prenatal evaluation includes targeted sonographic examination for central nervous system and extra-central nervous system abnormalities, and diagnostic amniocentesis for chromosomal analysis and infectious disease studies. Individualized patient counseling is based on these test results. Optimal postnatal care involves appropriate pediatric neurologic and developmental specialists.
OBJECTIVE: To evaluate the efficacy of fetal nuchal fold thickness and proximal long bone biometric measurements in modifying Down syndrome serum screening risk in a population of women referred for second-trimester sonography. METHODS: Sonographic biometric measurements and biochemical markers were combined retrospectively for 2533 women with known pregnancy outcomes. Four different screening methods were compared: (1) advanced maternal age; (2) biochemical serum screening markers; (3) modification of serum screening risks on the basis of categorical cutoffs for nuchal fold and femur and humerus length; and (4) a combined approach in which the sonographic measurements were treated as multiples of the medians and entered, together with the serum screening results, into a multivariable algorithm. The efficacy was compared at second-trimester risk cutoffs of 1:270 and 1:100. RESULTS: Down syndrome was present in 30 of the 2533 pregnancies (1 in 84). With the use of the 1:270 cutoff, biochemical screening had 93% sensitivity and a 40% false-positive rate. With application of the categorical method of fixed cutoffs to incorporate fetal biometry, the false-positive rate was reduced to 33% with no loss of sensitivity. The combined model had 83% sensitivity and a 19% false-positive rate. The combined method had the highest positive predictive value (1 in 20). Similar gains in efficacy could be shown with the 1:100 cutoff. CONCLUSIONS: For this high-risk group, the multivariate model that combines serum screening and sonography can result in a substantial reduction in the number of amniocenteses. Although the addition of the sonographic biometric measurements resulted in some Down syndrome cases being missed, the net effect was a large improvement in the overall positive predictive value of the screening.
OBJECTIVE: To determine whether prenatally diagnosed intracardiac echogenic foci are associated with childhood cardiac dysfunction and persistence. METHODS: Children in whom intracardiac echogenic foci were shown on prenatal sonography at 1 perinatal center underwent echocardiography at ages 2 to 7 years. A single pediatric cardiologist, blinded to the prenatal sonographic intracardiac echogenic focus locations, assessed cardiac function by measuring the left ventricular shortening fraction and myocardial performance index. The presence of tricuspid and mitral valve regurgitation was also sought. The secondary outcome was intracardiac echogenic focus persistence. RESULTS: Twenty-five children, 14 (56%) male and 11 (44%) female, were examined at a mean age +/- SD of 3.0 +/- 1.0 years. Prenatally, 18 children (72%) had left ventricular intracardiac echogenic foci, and 7 (28%) had right ventricular intracardiac echogenic foci. The left ventricular shortening fraction was normal in all children. The overall mean left ventricular myocardial performance index (reference value, 0.36 +/- 0.06), was normal for both children with left ventricular intracardiac echogenic foci (0.36 +/- 0.06) and those with right ventricular intracardiac echogenic foci (0.36 +/- 0.04). Two children with left ventricular intracardiac echogenic foci had an isolated left ventricular myocardial performance index of greater than 2.5 SD above the mean. Trace tricuspid valve regurgitation and mitral valve regurgitation were noted in 13 (52%) and 2 (8%) of the children, respectively, similar to the general population. Left ventricular intracardiac echogenic foci persisted in 16 children (89%), whereas right ventricular intracardiac echogenic foci persisted in 2 (29%) (P = .007). CONCLUSIONS: Prenatally diagnosed intracardiac echogenic foci are often persistent but not associated with childhood myocardial dysfunction.
OBJECTIVE: To describe the sonographic features of diastrophic dysplasia in 2 second-trimester index offspring. METHODS: Real-time sonography was performed on 2 second-trimester fetuses with no risk factors for skeletal dysplasia. RESULTS: Each fetus had severe bilateral upper and lower extremity long bone shortening, hitchhiker thumbs and great toes, and clubbed feet, indicating a diagnosis of diastrophic dysplasia. CONCLUSIONS: Index cases of diastrophic dysplasia may be correctly diagnosed on the basis of second-trimester sonography.
OBJECTIVE: To examine the ability of a universal screening strategy to identify and treat group B Streptococcus-positive women with intrapartum antibiotics. STUDY DESIGN: Charts were reviewed on all patients delivering at > or = 36 weeks of gestation as to the presence of culture results, whether or not antibiotics were ordered and when they were given relative to the time of delivery. RESULTS: Approximately 95% of patients presenting at > or = 36 weeks had group B Streptococcus results available. Overall, 84% of culture-positive patients received chemoprophylaxis. Removal of the elective cesareans from the study population increased the percentage of positive patients receiving antibiotics to 94%. Ideal chemoprophylaxis, defined as delivering > or = 2 hours after receiving the recommended antibiotics, occurred 87% of the time. Failure to order appropriate antibiotics was the most frequent reason for not receiving chemoprophylaxis. CONCLUSION: Successful universal culturing followed by intrapartum chemoprophylaxis can be accomplished in a majority of cases. Failure to treat can occur (6%), and chemoprophylaxis may be less than ideal (13%) due to rapid labor and human error.
BACKGROUND: Echogenic papillary muscles are noted in 30% of fetuses with trisomy 13. All reported fetuses with trisomy 13 and echogenic papillary muscles have exhibited additional abnormal sonographic findings. CASE: A 21.7-week fetus demonstrated three papillary echogenicities in each cardiac ventricle during ultrasound examination. Chromosomal analysis of amniocytes showed the karyotype 47,XX,+13. CONCLUSION: Multiple bilateral papillary muscles may provide the only sonographic sign of fetal trisomy 13.
Bladder carcinoma in situ is often treated with intravesical bacille Calmette-Guérin. Unable to find a report of this therapy in pregnancy, we describe such a case. Intravesical bacille Calmette-Guérin immunotherapy may be safely administered during the second trimester in an appropriately selected patient.
Extralobar pulmonary sequestrations are usually thoracic or abdominal lesions. A 29-week fetus demonstrated a 3.1 x 2.1 x 2.3 cm intrapericardial mass on ultrasonography. Magnetic resonance imaging demonstrated an extracardiac origin and suggested a pulmonary sequestration, which was confirmed after successful postnatal resection. Extralobar pulmonary sequestration should be considered in the presence of a fetal intrapericardial mass.
A fetus with mature amniotic fluid lung indices was delivered with subsequent respiratory distress syndrome, demonstrating that fetal pulmonary maturity needs to be viewed as a probability. We calculated the probability of respiratory distress as a function of gestational age and fetal lung maturity. The percent risks are displayed in an easily readable table format.
UNLABELLED: The purpose of this review is to evaluate tumor presentation and characteristics, and maternal-fetal outcomes of pregnancies complicated by nonbilharzial bladder carcinoma. The mean age of the patients was 29.5 years (range = 18-40). Symptoms and diagnosis occurred after the first trimester in 20 (83%) and 22 (92%) cases, respectively. Presenting complaints included painless gross hematuria [N = 12 (50%)], vaginal bleeding [N = 7 (29%)], dysuria [N = 2 (8.4%)], abdominal pain [N = 2 (8.4%)], and 1 instance each of urgency, frequency, recurrent cystitis, and no symptoms. Tumors were initially identified by ultrasound [N = 12 (50%)], cystoscopy [N = 11 (46%)], and intravenous urography [N = 1 (4.5%)]. Transitional cell carcinoma was found in 17 (74%), adenocarcinoma in 5 (22%), and squamous cell carcinoma in 1 (4.5%) patient. Tumors did not favor a specific bladder location, tended to be low grade [8 (40%) = grade 1, 7 (35%) = grade 2; 5 (21%) = grade 3], and noninvasive [N = 19 (79%)]. Treatment was typically by transurethral resection (N = 18), but 3 women required radical cystectomy, 2 received radiation, 1 received chemotherapy, and 1 underwent partial cystectomy. Three (14%) women died of their disease and 3 (14%) fetuses were lost because of complications of cancer or its treatment. Bladder carcinoma in pregnancy can mimic cystitis or obstetric hemorrhage and should be considered when evaluations for these conditions are negative. Routine ultrasound evaluation of the bladder in these patients may improve the diagnostic yield. Pregnancy is not a contraindication to treating most forms of bladder cancer. TARGET AUDIENCE: Obstetricians and Gynecologists, Family Physicians. LEARNING OBJECTIVES: After completion of this article, the reader will be able to list the various types of bladder cancers, to describe the presenting symptoms in a patient with a bladder cancer, and to outline the work up and treatment strategies for bladder cancer.