Cancer in pregnancy: a review of the literature. Part II.
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Female↗
Biomedical subjects
V L Katz
Publications and source records attributed to V L Katz.
Cesarean delivery for fetal malformations.
We reviewed existing data on fetal abnormalities to provide guidelines to determine which conditions have an improved neonatal outcome by cesarean delivery. We used Medline database to search for English language papers on a variety of fetal conditions that could influence the mode of delivery. We reviewed these sources with particular attention to how the mode of delivery influenced neonatal outcome. Conflicting data exist regarding optimal mode of delivery for many fetal conditions. Cesarean delivery may improve neonatal outcome for fetuses with isolated meningomyelocele, hydrocephalus with concomitant macrocephaly, anterior wall defects with extracorporeal liver, sacrococcygeal teratomas, hydrops, and alloimmune thrombocytopenia with low platelet count at term. Hydrocephalus without macrocephaly, anterior wall defects without an extracorporeal liver, ovarian cysts, skeletal dysplasias, fetuses whose mothers have immune thrombocytopenic puer-pura and fetuses with alloimmune thrombocytopenia with acceptable platelet counts may safely be delivered vaginally.
Cesarean Section↗
Methotrexate and angiographic embolization for conservative treatment of cervical pregnancy.
Cervical pregnancy has traditionally been treated by hysterectomy. Recent reports of the use of methotrexate have been encouraging as a potential conservative approach. We present a case of a cervical pregnancy diagnosed at 8 weeks' gestation in a woman who greatly desired fertility. She was treated successfully with a combination of multidose intramuscular methotrexate (1 mg/kg/day) and citrovorum rescue. When profuse bleeding developed on day 8, angiographic embolization was used to obviate surgery. The beta-hCG titer peaked at 58,362 IU/mL and was undetectable by postchemotherapy day 30. No blood transfusion was required, and reproductive capacity was spared. Four months after the cervical pregnancy, the patient became pregnant and had a healthy infant. Medical management of cervical pregnancy is an option when reproductive capacity is desired in selected patients with appropriate counseling.
Adult↗
Fatal lupus pleuritis presenting in pregnancy. A case report.
BACKGROUND: Lupus, one of the most common autoimmune diseases in pregnancy, may involve multiple organ systems with varying severity. The diagnosis and treatment of the disease may be complicated by the physiologic changes of pregnancy. CASE: A 22-year-old woman presented at 29 weeks' gestation with a 4-week history of dyspnea and mild hypertension. She was found to have large bilateral pleural effusions. Her antinuclear antibody level was 1:640, with a speckled pattern, and her complement levels were low. Her urine had 2+ hemoglobin and 2+ protein with hyaline casts. Over the next three days, respiratory compromise increased despite high-dose steroids. A cesarean delivery was performed for fetal compromise. The infant did well after moderate respiratory distress. The mother developed worsening respiratory distress with adult respiratory distress syndrome, and she could not be weaned from the ventilator. Bilateral chest tubes were placed to control her effusions. Urine output remained poor despite pressors and diuretics. Staphylococcal sepsis occurred on postoperative day 5 and precluded our use of other antiinflammatory agents. Over the next 14 days the mother developed seizures, hypotension and eventual respiratory collapse. Autopsy was notable for lupus nephritis and serositis. CONCLUSION: The diagnosis and management of systemic lupus in pregnancy may be extremely difficult. Serositis and nephritis may lead to maternal compromise despite early diagnosis and treatment.
Adult↗
Successful treatment of a cervical pregnancy with a single low dose methotrexate regimen.
Until very recently cervical pregnancies have been treated with surgery, usually hysterectomy. The development of endovaginal ultrasound, which allows early diagnosis, and methotrexate chemotherapy have opened up new therapeutic options. A 45-year-old multigravida presented at 8 weeks' gestation with vaginal bleeding. Endovaginal ultrasound demonstrated a cervical pregnancy with a fetal pole, 1.2 x 1.4 cm sac, no cardiac pulsations, and an empty uterus. After discussion with the patient, single low dose methotrexate 1.5 mg/m2 was given intramuscularly. The patient's hCG titre was 5882 IU-(Third International Standard). Over a 5-week period the hCG titres fell, and the gestational sac disappeared. The patient experienced intermittent vaginal bleeding and cramping but was managed as an outpatient. Single low dose methotrexate may be a successful management option in selected cases of cervical pregnancy.
Cervix Uteri↗
Prenatal diagnosis and management of massive bilateral axillary cystic lymphangioma.
BACKGROUND: Fetal lymphangiomas can occur in many different anatomic locations, including the most commonly seen nuchal cystic hygroma. CASE: A fetus at 18 weeks' gestation was found to have a massive right axillary hygroma. The fetal karyotype was normal. Serial ultrasound examinations indicated progressive enlargement, but no hydrops. At 32 weeks' gestation, a left axillary hygroma was also diagnosed. The patient underwent cesarean delivery. CONCLUSION: Prenatal diagnosis of nuchal cystic hygromas has a high association with karyotypic abnormalities, hydrops, and fetal demise; however, this association may not apply to cystic lymphangiomas at other locations.
Adult↗
Non-immune hydrops after 20 weeks' gestation: review of 10 years' experience with suggestions for management.
OBJECTIVE: To analyze the etiologies and outcomes for a southeastern section of the United States, and to organize an efficient approach to evaluation. METHODS: We reviewed 82 cases of non-immune hydrops presenting after 20 weeks' gestation over a 10-year period. RESULTS: Overall perinatal mortality was 86.6%. Fetuses diagnosed with hydrops before 24 weeks' gestation had a perinatal mortality of 95%, with nearly one-third having abnormal karyotypes. The etiology of hydrops diagnosed after 24 weeks' gestation was more likely to remain idiopathic or to be related to cardiothoracic abnormalities. CONCLUSION: Before 24 weeks' gestation, the high risk of mortality and abnormal karyotype justifies offering families funipuncture in the hope of finding a treatable cause of non-immune hydrops. After 24 weeks' gestation, when fewer abnormal karyotypes are found, funipuncture may also be pivotal in diagnosing the cause of non-immune hydrops.
Adult↗
Cesarean delivery: a reconsideration of terminology.
The terminology we employ influences our perceptions. Thus, we believe in reviewing terminology regularly. The term "cesarean section" should be abandoned. A medical procedure is rarely named after a historic figure, and almost never after an ancient Roman law. Cesarean section has recently been amended to cesarean birth; however, the term is still inadequate. The word "hysterotomy" more appropriately describes the procedure we regularly perform. The adjectives used to describe cesarean birth should also be reevaluated. If we are to keep the term "classical" for the original fundal vertical uterine incision, then the other designations of hysterotomy should retain the same architectural context. Contemporary hysterotomy should be used in reference to a low transverse cesarean. Neoclassical hysterotomy might be used to describe the low vertical procedure. Transitional hysterotomy may be an appropriate term for the "hockey stick" or "J" incision. Cesarean delivery best describes a postmortem cesarean. Vaginal birth after cesarean (VBAC) is inappropriate because a vaginal birth after a cesarean section would not occur if cesarean section refers to a perimortem procedure. Vaginal birth after hysterotomy should be substituted for VBAC. Such revision of our terminology will keep obstetrics at the forefront of medical science and bring us most efficiently into the 21st century.
Cesarean Section↗
Outcome of pregnancies with elevation of both maternal serum alpha-fetoprotein and human chorionic gonadotropin.
We evaluated the pregnancy outcome of all patients with elevations of both maternal serum alpha-fetoprotein and human chorionic gonadotropin since institution of combined serum screening at our program. After analysis of 34,404 samples, 99 patients were found to have significant elevations of both maternal serum alpha-fetoprotein and human chorionic gonadotropin. The ultrasound findings, amniocentesis results, and pregnancy outcomes were determined in each case. Sixty-six patients with singleton gestations met entry criteria. Pregnancy outcome information is available for 63 of these patients, 60% of whom had at least one complication. Thirty-three patients with multiple gestations met inclusion criteria. Pregnancy outcome information is available for 31 of these, 81% of whom had at least one complication. These patients had a high incidence of pregnancy related complications. This group would appear to be at higher risk than women with elevation of either maternal serum alpha-fetoprotein or human chorionic gonadotropin alone.
Amniocentesis↗
Course of Crohn's disease during pregnancy and its effect on pregnancy outcome: a retrospective review.
The purpose of our study was to review the effects of Crohn's disease on pregnancy outcomes. Over a 6-year period, we identified 17 women with pregnancies complicated by Crohn's disease. The mean age of the women was 26 years, with a mean age of diagnosis at 17 years. Crohn's disease worsened only slightly during the pregnancy. Exacerbations of diarrhea were the main problems. Weight gain, unadjusted for gestational age at delivery, was 18 pounds. Three babies had low birthweight; two were both premature and growth retarded. One woman with active disease and no prenatal care had a fetal death at 30 weeks' gestation with subsequent disseminated intravascular coagulation. Among women with active perianal disease, one was delivered vaginally without exacerbation of symptoms. Four women with histories of perianal disease had prophylactic primary elective cesarean sections to avoid worsening of symptoms. Three of these women developed recurrent perianal disease despite the abdominal delivery. One of these developed an abdominal fistula trait in the wound. Our findings suggest that active disease at the onset of pregnancy tends to remain active, and quiescent disease tends to remain quiescent. Mode of delivery in our series was not protective against perineal disease. Although our series is small, it suggests that delivery may occur vaginally, with operative delivery reserved for obstetric indications.
Adolescent↗
Pressor response to cycle ergometry in the midtrimester of pregnancy: can it predict preeclampsia?
Ninety-seven primigravid patients were prospectively studied to assess the predictive value of the pressor response to aerobic exercise as a screening test for preeclampsia. The blood pressure response to cycle ergometry exercise to a maternal pulse of 140 beats/min was recorded on each subject. Each subject was studied in the second trimester of pregnancy at a mean gestational age of 23 weeks (range, 18 to 27). Three of the study subjects developed hypertension with proteinuria in the third trimester. A rise in systolic blood pressure of at least 30 mm Hg occurred in 29 patients, but this did not predict third trimester preeclampsia (p = 0.21). A rise in diastolic blood pressure of 20 mm was observed in 18 patients, two of whom developed preeclampsia (p = 0.08). An increase of diastolic pressure of 20 mm Hg with moderate cycle ergometry exercise in the second trimester may predict a subset of patients at elevated risk of preeclampsia in the third trimester. However, the positive predictive value of this 20 mm Hg pressor increase (11%) limits its applicability as a screening test. Thus, we cannot recommend the use of an exercise screening test at this time.
Blood Pressure↗
Maternal and fetal responses to low-impact aerobic dance.
The purpose of this study was to compare the physiologic responses to low-impact aerobics using treadmill walking as a control. Ten pregnant women between 21 and 28 weeks of gestation completed 40 minutes of low-impact aerobic dance. The maternal and fetal responses were then compared to 40 minutes of walking at the same heart rate. The aerobics program consisted of a 10-minute warm-up, 20 minutes of high-intensity exercise, and 10 minutes of decreasing intensity. Heart rates were recorded every 5 minutes, and oxygen uptake (VO2) and fetal response (real-time ultrasound) were obtained every 10 minutes. The maternal heart rates were similar during both trials (overall, 133 +/- 6 beat/min). VO2 values during walking were about 4 mL/kg/min greater than during aerobic dance (p < or = 0.003). Minute ventilation (VE) was also greater during walking (28.7 +/- 6.4 versus 24.1 +/- 3.4 L/min, p < or = 0.001). Respiratory exchange ratios and the ventilatory equivalents for oxygen (VE/VO2) were similar for both trials. Aerobic dance caused greater fetal heart rates than walking (p < or = 0.001), differences being as high as 25 beat/min. The fetal rates had returned toward rest within 5 minutes following exercise. Low-impact aerobic dance, compared with walking at similar heart rates, results in a lower maternal metabolic rate and increases the transient stress on the fetus.
Adult↗
6-sulfatoxymelatonin levels in pregnant women during workplace and nonworkplace stresses: a potential biologic marker of sympathetic activity.
Melatonin production is regulated by both catecholamines and sympathetic activity. Urine levels of the major metabolite of melatonin, 6-sulfatoxymelatonin, correlate well with serum melatonin levels and have been used to evaluate sympathetic output. We tested the hypothesis that urinary levels of 6-sulfatoxymelatonin would reflect the change in adrenergic activity on working days compared with nonworking days during pregnancy. Twenty-three healthy pregnant women, employed in a variety of occupations, including physicians, nurses, secretaries, salespeople, and laboratory workers were recruited from the clinics of the University of North Carolina School of Medicine. We measured 6-sulfatoxymelatonin levels in first morning voids and for the subsequent 10 hours at 24, 28, 32, and 36 weeks' gestation. Urine was collected in sets during working days and during nonworking days. 6-Sulfatoxymelatonin was measured by radioimmunoassay. In 11 women we also measured urine catecholamines by high-performance liquid chromatography. Levels of 6-sulfatoxymelatonin output did not change across gestation, although they tended to drift down as pregnancy progressed. Median levels at first morning void were 6.3 micrograms on workdays and 4.6 micrograms on nonworkdays. Although all values were skewed toward work being greater than nonwork, there were large interindividual variations. We therefore compared subjects against themselves and compared work levels for each subject to the corresponding gestational age-matched nonwork value. Among the 23 women, median 6-sulfatoxymelatonin levels were 81% greater during work than nonwork (p < 0.0002) when first morning collections were compared. Daytime urinary excretion of 6-sulfatoxymelatonin on workdays was 38% (p < 0.005) greater than during nonworkdays.(ABSTRACT TRUNCATED AT 250 WORDS)
Biomarkers↗
Alpha 1-antitrypsin deficiency and pregnancy.
Alpha1-antitrypsin deficiency is an inherited pulmonary disorder which results from a deficiency of a major plasma protease inhibitor. The onset and severity of symptoms vary widely and depend on the genotype and whether the patient smokes cigarettes. Alpha1-antitrypsin in pregnancy has only been previously reported twice. Our patient had a functional serum alpha1-antitrypsin level which was 15% of normal but was clinically asymptomatic and she did not smoke. Her genotype revealed a non-ZZ pattern. Her obstetric history was complicated by preterm labor in each of her five ongoing pregnancies. Alpha1-antitrypsin deficiency is inherited via two codominant autosomal genes. Although there is great variability in severity of disease, seriously affected patients may have emphysema and hepatic abnormalities. Patients with non-ZZ genotypes or who are heterozygotes may have favorable pregnancy outcomes.
Adult↗
Bacterial vaginosis in pregnancy: an approach for the 1990s.
It is proposed that clinicians screen all pregnant women at high risk for preterm labor and premature rupture of membranes for bacterial vaginosis, and treat all women when it is diagnosed. This infection is associated with a two to three times increase in preterm labor and delivery, premature rupture of the membranes, and endometritis. Although cause and effect have not been conclusively documented, these associations must be considered in the practice of obstetrics at the present. The paucity of vaginal Lactobacillus spp is pivotal in allowing overgrowth of many other organisms of the vagina. Screening is suggested because 50 percent of bacterial vaginosis is asymptomatic. The diagnosis, which is rapidly made and inexpensive, remains defined by clue cells seen on wet prep, high vaginal pH, and amine odor of the vaginal discharge. Optimal treatment of pregnant women with bacterial vaginosis is via oral or intravaginal metronidazole or clindamycin.
Clindamycin↗
Pregnancy complicated by Guillain-Barré syndrome.
We report a case of a pregnant patient with Guillain-Barré syndrome. Her symptoms, including weakness, vague numbness, urinary incontinence, and unsteady gait, were initially mild and mimicked many of the changes seen in pregnancy. Her progressive weakness was not preceded by any known illness. Evaluation of symptoms revealed an elevated cytomegalovirus IgM titer. When symptoms became severe, electromyography was done, showing a severe demyelinating motor-sensory neuropathy. After plasma exchange and vaginal delivery, symptoms resolved. Neither the patient nor her infant have had any long-term sequelae. Guillain-Barré syndrome may be difficult to diagnose in pregnancy but may be effectively treated with plasmapheresis.
Adult↗
HIV infection in pregnancy. A review of current developments.
It appears that pregnancy itself is not adversely affected by HIV infection, but the course of HIV infection in the mother may be accelerated by pregnancy. The results of the 076 trial have changed our approach to AIDS in pregnancy. Heretofore AZT was only given for maternal indications such as severe immunodeficiency (CD4 count less than 200). We now recommend that AZT be given to all women with HIV infection and to infants postpartum. As to mode of delivery, Cesarean section may be beneficial, but we await further studies. We strongly encourage all pregnant women to have HIV testing regardless of risk factors. The HIV epidemic is here, in North Carolina. It is our responsibility as doctors to help pregnant women as best we can with their disease.
Acquired Immunodeficiency Syndrome↗
Varicella during pregnancy. Maternal and fetal effects.
To determine the characteristics of maternal varicella at our institution, we reviewed all cases of primary varicella in pregnancy. Using a perinatal database that summarizes all obstetric admissions, we reviewed the medical records of women with varicella infections during pregnancy. Over a 5 1/2-year period, 31 pregnancies were affected by varicella infection among 11,753 deliveries. The mean age of those patients was 19.6 years, significantly different from our overall population of 25.3 years (P < .05). The racial composition of 35% Hispanic, 35% white, and 29% African American was different from that of our general population of 55% white, 38% African American, and 6% Hispanic (P = .023). The mean gestational age of the eruption of vesicles was 25 weeks. Of the 31 women, 7 had preterm labor within a week of their varicella, 3 delivered prematurely, and 3 infants had a birth weight of less than 2,700 grams. Respiratory symptoms developed in 6 women, and pneumonia developed in 4, 2 of whom required ventilatory support, 1 for 5 days, the other for 49 days. Eight women received acyclovir during gestation, and none suffered sequelae. In all, 6 infants had lesions and anomalies noted at birth, 5 possibly associated with varicella. Varicella infection is associated with a greater-than-expected level of both maternal and fetal morbidity. The fetal disease may occur due to maternal infection at any gestation and is most likely a spectrum of complications. The maternal disease appears to be worse in the latter half of pregnancy. Programs of prevention through vaccination must account for a possibly decreased level of immunity in different populations.
Acyclovir↗