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Numerous complications can prevent the successful outcome of a pregnancy conceived while a woman is undergoing chronic hemodialysis. Among the difficulties encountered, premature labor and polyhydramnios are common. In such a patient indomethacin was used to treat those problems, with the subsequent delivery of a healthy infant.
A neonate was born prematurely with polyhydramnios and yellow amniotic fluid. He developed gastric retention and bilious vomiting. Abdominal röntgenography showed jejunum atresia.
Preterm birth (defined as delivery prior to 37 weeks' gestation) complicates 5-10% of all births. It is a major cause of perinatal mortality and morbidity. Approximately 20% of all preterm births are iatrogenic resulting from obstetric intervention for maternal and/or fetal indications. Of the remainder, 2/3 are spontaneous preterm labor with or without preterm premature rupture of the membranes (pPROM). Preterm labor is a syndrome rather than a diagnosis since the etiologies are varied. Risk factors include, among others, pPROM, cervical insufficiency, pathologic uterine distention (polyhydramnios, multiple gestation), uterine anomalies, intrauterine infection/inflammation, and social factors (stress, smoking, heavy work). The final common pathway appears to be activation of the inflammatory cascade. Bacterial colonization and/or inflammation of the choriodecidual interface induces production of pro-inflammatory cytokines that, in turn, lead to neutrophil activation and the synthesis and release of uterotonins such as prostaglandins (which cause uterine contractions) and metalloproteinases (that weaken fetal membranes and remodel cervical collagen). This monograph reviews the role of cytokines in the pathophysiology of preterm labor and delivery.
A facial malformation was diagnosed by ultrasonography, the case correspond to First Arch syndrome, the findings are micrognathia, polyhydramnios, low-set ears and absence of stomach bubble. The heterogeneity of this syndrome and his relationship with environmental agents is analyzed.
A case is reported in which exposure to cocaine and indomethacin was associated with development of fetal anuria, anasarca, and neonatal gastrointestinal hemorrhage. Cocaine and indomethacin may act synergistically to adversely affect renal, cardiovascular, and platelet function. It may be prudent to obtain a drug history and urine screen for cocaine before instituting indomethacin therapy for preterm labor or polyhydramnios.
Bilateral pleuroamniotic shunting was performed at 33 weeks' gestation in a fetus with bilateral hydrothorax, hydrops, and gross polyhydramnios. The procedure was successful, but acute amniotic fluid leakage into the maternal peritoneal cavity occurred soon after. This produced marked maternal discomfort and transient oligohydramnios, with consequent fetal distress. Expectant management was adopted in view of fetal lung immaturity. Resolution of maternal ascites occurred within 24 hours and the fetal heart rate normalized as amniotic fluid reaccumulated. The pregnancy progressed uneventfully thereafter.
Continuous-wave Doppler ultrasound was used to assess blood flow velocities and determine the pulsatility index of the uterine arteries in ten pregnant women at 23-33 weeks' gestation during indomethacin therapy for preterm labor or polyhydramnios. There was no statistically significant difference in the pulsatility index of the uterine arteries during maternal indomethacin treatment (mean +/- SD 0.85 +/- 0.29) compared with pre-treatment values (0.85 +/- 0.23). Although studies in animals have reported that indomethacin increases uterine impedance to flow, it appears that it does not affect the uterine impedance in humans.
To develop prognostic indicators for those patients diagnosed with twin-twin transfusion before 28 weeks' gestation, we conducted a retrospective analysis of all cases diagnosed at Baylor College of Medicine from January 1985 through April 1989. Twenty-seven cases of twin-twin transfusion were diagnosed by ultrasound; the criteria for diagnosis were polyhydramnios in one amniotic cavity and oligohydramnios in the other cavity. The mean (+/- SD) age at diagnosis was 21.9 +/- 2.9 weeks and the mean age at delivery was 26.8 +/- 4.9 weeks. Gestational age at diagnosis was similar in survivors and non-survivors (21.7 +/- 3.7 versus 22.2 +/- 2.8 weeks; P = .35); however, surviving infants were delivered later in gestation (31.9 +/- 3.5 versus 25.9 +/- 3.4 weeks; P = .000008). The overall survival rate was 21%. Fetal hydrops correlated with poor survival. Amniocentesis for decompression and tocolysis failed to decrease perinatal mortality.
We present a first case in whom fetal hypothyroidism with goiter was both successfully diagnosed and treated in utero. An obstetrical sonogram at 33 weeks revealed a bilobed fetal neck mass, compatible with enlarged thyroid gland, associated with neck hyperextension, reduced gastric fluid, and polyhydramnios. Umbilical blood sampling after volume reduction amniocentesis confirmed fetal hypothyroidism with a euthyroid mother. Fetal T4 measured 1.3 micrograms/dl, free T4 0.3 ng/dl, and thyroid-stimulating hormone 186 microU. Intraamniotic levothyroxine, 500 micrograms, was given twice with a 14-day interval. The head flexed, gastric fluid increased, and amniotic fluid levels returned to normal. Prenatal (36 weeks) and neonatal blood sampling demonstrated return to euthyroid indices. Ultrasonic estimates of thyroid volume decreased by over 50%. Vaginal delivery at 39 weeks was uncomplicated. The newborn appeared normal and is being maintained on thyroid replacement therapy.
Prenatal sonographic findings in one case of gastric obstruction due to an imperforate antral diaphragm and in one case of duodenal atresia are presented. The combination of either one or two prominent sonolucent areas in the upper or mid fetal abdomen and polyhydramnios is virtuallydiagnostic of high obstruction.
The ultrastructure of the amniotic epithelial cells from normal, polyhydramnic, and oligohydramnic pregnancies were studied with the transmission electron microscope. The amniotic epithelial cell layer from normal pregnancies was 8- to 12-mu thick. In polyhydramnic pregnancies the cell layer varied widely from the normal thickness to as much as 18 to 56 mu in diabetic patients. Other ultrastructural changes observed in pregnancies complicated by polyhydramnios were abnormal microvilli, diminished intercellular canals, increased tonofilaments, and decreased rough-surfaced endoplasmic reticulum. In pregnancies complicated by oligohydramnios the thickness of the cell layer was 3 to 6 mu. The amniotic epithelial cells had increased tonofilaments, decreased desmosomes, collapsed and fused intercellular canals, and caused a marked decrease of the Golgi apparatus and the rough-surfaced endoplasmic reticulum. The sparse microvilli were short, plump, and had bizarre shapes.
The case of an infant born in association with a large chorioangioma of the placenta is presented. The maternal complications of polyhydramnios, preeclampsia, and premature labor are those described in the "syndrome" of a chorioangioma. The immediate neonatal course was unusually complicated by severe microangiopathic anemia with persistent thrombocytopenia and hemolysis which required three exchange blood transfusions. The relationship between the neonatal complications and the placental tumor is discussed in terms of possible pathophysiologic mechanisms.
Bartter syndrome was diagnosed in two siblings born to healthy unrelated parents. Each pregnancy was complicated by severe polyhydramnios. The first child was treated with indomethacin from the age of then weeks on. At the age of six years he is doing very well: height is 109.9 cm (P3) and weight 17.8 (P3). Studies of the amniotic fluid during the mother's second pregnancy showed high chloride concentrations (112, 117, and 119 mEq/l), normal levels of sodium, potassium, calcium and creatinine and low prostaglandin E2 (5.0-22.3 pg/ml) and F2 alpha (36-71.7 pg/ml) concentrations. Severe chloride and sodium wasting after birth resulted in hypochloremia, hyponatremia and dehydration. Concomitantly an immediate and striking increase in urinary PGE2 excretion from 45 to 1022 pg/ml was observed. Indomethacin therapy had to be stopped after one week when necrotising enterocolitis developed.
Camptodactyly and pulmonary hypoplasia syndrome was described for the first time in 1974. Today 15 cases have been found. None were subject to a prenatal diagnosis as any ultrasonography. The case we observe is a 27 years old woman, third gestation, showing a polyhydramnios at 25 weeks of gestation. The ultrasonographic examination showed deformation with a rounded abdomen, a narrow thoracic frame slightly concave, no gastric picture and hands in constant flexion. After elimination of the V.A.T.E.R.' syndrome the camptodactyly's syndrome with pulmonary hypoplasia was proposed. Because of the lethal character of this syndrome, the abortion was realised. The photos of the fetus were the same as the ultrasonographic pictures during the prenatal diagnosis. The absence of intrinsic (paralysis) or extrinsic (compression) movements of the fetus is very important in the genesis of "deformations". The severity of the deformities depends on the importance of akinesia.
A case of congenital chylothorax presented as polyhydramnios and massive fetal edema. The diagnosis was suspected prior to delivery on the basis of ultrasonography. Ultrasound was helpful in localizing the fluid for postnatal thoracentesis. Congenital chylothorax is part of the differential diagnosis of nonimmune hydrops fetalis.
Transplacental feto-maternal hemorrhage was diagnosed after delivery of a highly anemic infant from a healthy mother with polyhydramnios by demonstration of fetal red cells in the maternal circulation (145 degrees/00) using a modified Kleihauer technique. Other causes for anemia such as hemolysis, coagulopathies, failure of red cell production or perinatal posttraumatic bleeding were excluded. The transfused volume estimated eexceeded the blood volume of the newborn by several times, thus indicating a chronic blood loss. This was confirmed by hematologic data typical for a normovolemic anemia, a low serum iron level and the development of a congestive heart failure in the newborn infant.
Thirty cases of nonimmunologic hydrops fetalis in 14 hospitals were studied. The incidence of nonimmunologic hydrops fetalis was 1 in 4,330 deliveries at all hospitals and 1 in 4,389 deliveries at Tokyo University Hospital. Among these, 13 cases with various kinds of fetal anomalies and 5 cases complicated by twin to twin transfusion syndrome were found. Polyhydramnios (73%), preeclampsia (20%), anemia (34%), and hypoproteinemia (64%) were the commonest prenatal maternal complications, whereas a high incidence of abnormal NST patterns such as loss of variability was found, although urinary E3 levels were within the normal range. High rates of premature labor, Caesarian section and vacuum extraction were found at the deliveries of nonimmunologic hydrops fetalis. Prenatal diagnoses were made in 30% and 85% of the cases before 1977 and between 1978 and 1982, respectively. Ultrasound examination was confirmed to be very useful in detecting the hydropic state in the later period. The perinatal mortality rate from nonimmunologic hydrops fetalis was high (90%); and it was 100% in the cases with anomalies or twin to twin transfusion syndrome. The main cause of neonatal death was respiratory insufficiency due to hypoplasty of the lungs and pleural effusion.
In 20 years the authors have met with 115 cases of meconium peritonitis (MP). The high incidence in China is shown. In all cases there were intraabdominal calcifications. There were no cases of fibrocystic disease. The authors classify 3 types: 1. Neonatal obstructive type 41 cases. 2. Free perforation with: Free pneumoperitoneum 15 cases. Localized pneumoperitoneum 23 cases. 3. No signs or symptoms, with potential intestinal obstruction 23 cases. The series shows a low incidence of atresia. The authors suggest necrotizing enterocolitis as a cause because of the high incidence of stenosis. Three prenatally diagnosed cases are discussed. All had hydramnios and fetal abdominal calcifications. Two of these were confirmed after birth. The mortality is high (42.6%). Abdominal x-ray in all cases with polyhydramnios may lead to a positive diagnosis of MP.