Arda Lembet

Laparoscopic management of heterotopic cesarean scar pregnancy with preservation of intrauterine gestation and delivery at term: case report

OBJECTIVE To present a case of laparoscopic removal of a heterotopic cesarean scar pregnancy under ultrasound guidance. DESIGN Case report. SETTING Private hospital. PATIENT(S) A 34-year-old woman with heterotopic cesarean scar pregnancy. INTERVENTION(S) Laparoscopic removal of heterotopic cesarean scar pregnancy. MAIN OUTCOME MEASURE(S) Delivery at term after laparoscopic management of heterotopic cesarean scar pregnancy. RESULT(S) An ongoing intrauterine pregnancy ended with a live birth after successful removal of the heterotopic gestational mass by a laparoscopic approach. CONCLUSION(S) Surgical removal of the ectopic mass by laparoscopy may be a radical approach in cases of heterotopic cesarean scar pregnancy. Laparoscopic excision of the cesarean scar pregnancy gives the opportunity to preserve the viable intrauterine gestation while maintaining a strong lower uterine segment. Ultrasound is an adjunctive tool that enables precise location of the ectopic mass during the operation.

Genetic amniocentesis after multifetal pregnancy reduction

OBJECTIVE Our purpose was to evaluate the pregnancy loss rate resulting from genetic amniocentesis after multifetal pregnancy reduction. STUDY DESIGN A cohort study was performed in pregnancies with maternal age >30 years. Pregnancy loss in a study population of 127 patients who underwent genetic amniocentesis after multifetal pregnancy reduction were compared with a control group of 167 patients who did not have genetic amniocentesis after multifetal pregnancy reduction. RESULTS The pregnancy loss rate in patients who underwent genetic amniocentesis after multifetal pregnancy reduction was 3.1% (4/127 cases) compared with 7.2% (12/167 cases) in the controls (P >.05). In the study group evidence of infection was found in only 1 case, in which the pregnancy loss occurred 1 day after the amniocentesis. In the other cases the pregnancy losses occurred 5 weeks after genetic amniocentesis, and these losses could not be directly attributed to either genetic amniocentesis or the multifetal reduction procedure. CONCLUSION Our data suggest that the performance of genetic amniocentesis after multifetal pregnancy reduction does not increase the risk of pregnancy loss over that observed in association with the reduction itself.

Non-Invasive Management of Fetal Goiter during Maternal Treatment of Hyperthyroidism in Grave’s Disease

There is an increased risk of fetal goiter in patients who have a history of Grave’s disease and undergo propylthiouracil (PTU) treatment during pregnancy. In this report, we describe a case of a fetal goiter detected by antenatal ultrasound at the 26th week of gestation in a mother treated with PTU for Grave’s disease. A 32 × 38 × 20 mm fetal goiter was detected, each lobe measured 30 × 18 × 18 mm and estimated volume was 10 cm3. Subsequently, fetal thyroid function was assessed by umbilical fetal blood sampling. Cord blood showed elevated serum TSH (40.2 mU/l) and normal concentrations of free T4 (9.5 pmol/l) and free T3 (2.6 pmol/l). There were no other ultrasonographic signs of fetal hypothyroidism. Based on the above findings, the mother’s PTU dosage was reduced to 50 mg daily from a total of 150 mg and weekly ultrasonographic examinations were performed. Six weeks after the initial ultrasound, a complete regression of the fetal goiter was noted. At the 34th week of gestation, the patient was delivered due to intrauterine growth restriction and oligohydramnios and gave birth to a male, weighing 1,920 g. The newborn thyroid was not palpable and thyroid ultrasonography was normal. Cord blood TSH was normal (8.4 mU/l) and free T4 was within lower normal limit (9.03 pmol/l). Ten days later, newborn thyroid function was normal and the baby did well afterwards. In conclusion, after the evaluation of fetal thyroid status, selected cases with fetal goiter can be initially managed without intrauterine treatment.

Prenatal diagnosis of a partial monosomy 7q11-->q31 in a fetus with split foot.

Objective: A 27-year-old woman was referred to our laboratory for genetic counseling at 26 weeks of gestation due to abnormal ultrasound findings including intrauterine growth retardation, Dandy-Walker malformation and lower extremity anomalies. Methods: Chromosome analysis was performed on fetal blood sample obtained by cardiocentesis. Result: We observed an abnormal karyotype with a structural abnormality of the long arm of chromosome 7. Both parents’ chromosomes were normal; thus, the fetal karyotype designation was 46,XX, del(7)(pter→q11::q31→qter) de novo. Skin biopsy sample was taken to confirm the karyotype after therapeutic abortion was performed. The result was identical. Postmortem examination and autopsy showed facial dysmorphism, malformations of the lower extremities and central nervous system anomalies. Conclusion: 7q interstitial deletions cause a wide spectrum of congenital abnormalities and syndromes linked to the deleted segments. Our case had a rather wide chromosome region deleted and it is important, because prenatal diagnosis was performed. Thus, the family had the chance to evaluate the situation and decided to terminate the pregnancy after genetic counseling.

Transient osteoporosis of pregnancy: case report.

Transient osteoporosis of pregnancy is a rarely observed skeletal pathology developing in the last months of pregnancy. Meticulous evaluation is important for the differential diagnosis of severe and progressive hip and/or groin pain in pregnant patients. MRI is a valuable and safe technique for demonstrating bone marrow edema and skeletal abnormalities during pregnancy. Avoidance of vaginal delivery and non-weight bearing measures are essential in order to prevent complications such as hip fractures related to transient osteoporosis of pregnancy. We present the diagnostic evaluation and treatment of an uncommon case of transient osteoporosis of pregnancy with resolution of symptoms and postpartum.

Spontaneous Regression and Reaccumulation of Pleural Effusion in a Fetus

Isolated pleural effusion is rare and occurs when varying degrees of fluid surround the fetal lung without concomitant hydrops. The effusion may regress spontaneously, remain stable in size, or progress to involve both sides of the chest causing fetal hydrops. This may result in pulmonary hypoplasia and fetal or neonatal demise. In this article, we report a case in which spontaneous resolution of an isolated right-sided fetal pleural effusion occurred at 23 weeks of gestation and reappeared bilaterally at 34 weeks. Serial ultrasonographic evaluation of the fetus should be continued even if a spontaneous resolution of a preexisting pleural effusion has occurred.

Maternal-Fetal Factors That Affected Doppler Waveform Analysis in a Patient Undergoing Hemodialysis

Pregnancy in women having chronic renal insufficiency and undergoing hemodialysis is a rare event with a poor outcome. This is the 1st case in whom pre- and posthemodialysis fetal renal artery Doppler flow velocimetry was used in conjunction with fetal blood sampling which was performed to assess fetal karyotype and blood chemistry. Uteroplacental Doppler measurements were also performed, and a close correlation between maternal-fetal blood creatinine and urea nitrogen levels and fetal renal, umbilical, and uterine artery resistance indexes was observed.

P25.11: The OEIS complex presented with large umbilical cord cyst in early gestation

The OEIS complex (omphalocele, bladder exstrophy, imperforate anus, spine defect) is an extremely rare condition. The spectrum of defects is variable. The etiology is probably heterogeneous. The complexity of this malformation challenges the identification by ultrasound in early gestation. Most of the reported cases were diagnosed postmortem or postnatally. To our knowledge, we report the earliest diagnosed case of OEIS complex. A 30 year old primigravid woman was referred at 11 weeks and 2 days of gestation for nuchal translucency screening. The nuchal translucency was 1 mm. We detected a large umbilical cord cyst. The ultrasound examination was repeated at 12 weeks 2 days. Skin covered lumbosacral neural tube defect and ventral wall defect were suspected and bladder was not observed. The patient was reexaminated at 14 weeks 2 days. Three umbilical cord cysts, single umbilical artery, scoliosis and club foot were determined. The prognosis was explained and the family decided to terminate the pregnancy. Postabortal examination demonstrated absent external genitalia, exstrophy of bladder, imperforate anus, large omphalocele resulting from a median ventral wall defect at the caudal end of the body that resulted with the herniation of two lobes of liver, small intestine and one gonad. The defect was covered by a membrane composed of peritoneum and amnion. The histology of the gonads revealed a normally developed testis. Karyotype was 46, XY. X ray examination of the fetus demonstrated vertebral defects and autopsy findings were consistent with OEIS complex. Differential diagnosis includes cloacal extrophy, body stalk anomaly, amniotic band syndrome, isolated omphalocele and isolated neural tube defect. Probably early ultrasound diagnosis of OEIS complex with heterogeneous presentations will be possible with further accumulation of data in the literature. Although the risk of recurrence is very low, autopsy and fetal chromosome analysis should be offered in these cases.

OP10.05: Can multifetal pregnancy reduction alter uterine artery Doppler velocimetry?

Objectives: To determine whether the risk of fetal loss following trans-abdominal multifetal pregnancy reduction (TA-MFPR) of a monochorionic twin pair is similar to the one in dichorionic pairs. Study Design: A retrospective review of all TA-MFPR performed in our institution (1999–2007) was conducted. The procedurerelated fetal loss, defined as pregnancy loss prior to completion of 24 weeks, in pregnancies involving reduction of a monochorionic pair i.e. ‘‘Mono group’’ was compared to the loss rate in all other TA-MFPR i.e. ‘‘Non-mono group’’. This comparison was further stratified according to the specific pre and post reduction number of fetuses. Additionally, association between the number of needle insertions performed and the procedure related fetal loss was sought. Results: 394 TA-MFPR were eligible for analysis and an overall loss rate of 2.5% (10 of 394) was detected. The procedure related loss in the ‘‘Mono’’ and ‘‘Non-mono’’ groups as well as the impact of the pre and post reduction number of fetuses on the fetal outcome is displayed in table 1. Information regarding number of needle insertions was available on 182 TA-MFPR of which in 22 ‘‘Nonmono’’ and 16 ‘‘mono’’ cases the same needle insertion was used to reduce more than a single fetus. The loss rate for single, two and three needle insertions was 3/165, 0/11 and 1/6 respectively (pnon significant). Conclusions: Fetal loss following TA-MFPR is independent of the chorionicity of the pair reduced. Additionally, we noted a trend suggesting an increased risk for fetal loss with increased number of needle insertions. Since monochorionic twins carry an increased pregnancy-related complication rate, it is our practice to attempt reduction of such pairs, preferably by using a single needle insertion. This can be achieved by a careful selection of the needle pathway to reach both fetuses.

OP11.02: Correlation between first trimester serum PAPP-A, second trimester MSAFP and uterine artery blood flow

Objectives: It is well-known that pregnancies complicated with twin reversed arterial perfusion (TRAP) sequence are at risk for intrauterine demise of the pump twin at any stage of pregnancy. However, the cause(s) for this high mortality rate have largely remained unknown, with chronic hemodynamic overload and cardiac insufficiency being suggested as the main pathophysiologic events. We present evidence that acute fetal bleeding is a major cause for early intrauterine loss of the pump twin in TRAP sequence. Methods: Cases of TRAP sequence diagnosed in the first trimester were followed serially by ultrasound in order to detect rapid growth of the acardiac mass o any sign of cardiac decompensation in the pump twin. Cases ending in intrauterine demise of the pump twin before 16 weeks were identified and information on postpartum findings reviewed. Results: There were eight cases of TRAP sequence which complied with the entry criteria. Postmortmem examination, including pothographic material, of the pump and acardiac twins was available in five cases. In all, a pale pump twin and a reddish, hyperemic acardiac twin was found. There was no evidence of cardiac dysfunction in the acardiac twin in any of the cases. Conclusions: Acute blood loss into the acardiac mass seems to be a major cause for early intrauterine death of the pump twin in TRAP sequence. This is probably the result of acute obstruction of the venous return from the acardiac to the pump twin.