Carol C. Coulson

Pelvic magnetic resonance imaging in the evaluation of uterine torsion

Background Uterine torsion is defined as the rotation of more than 45° around the long axis of the uterus. An uncommon but potentially fatal event, uterine torsion is rarely diagnosed until the time of surgery. With magnetic resonance imaging (MRI), however, an accurate diagnosis of uterine torsion may now be made preoperatively. Case We describe a patient with uterine torsion in whom the correct diagnosis was made prenatally with the use of MRI, by the demonstration of an X-shaped configuration of the upper vagina. Conclusion Distinctive features suggestive of uterine torsion were demonstrated by MRI and enabled an accurate preoperative diagnosis. To our knowledge, this is the first reported case of uterine torsion diagnosed on MRI.

Prenatal sonographic diagnosis of axillary cystic lymphangiomas.

Cystic lymphangiomas are congenital malformations of the lymphatic system that occur most commonly in the nuchal region. Nuchal lymphangiomas are often referred to as cystic hygromas. Few cases of axillary cystic lymphangioma have been reported, but the prognosis of this lesion appears to be less grave than that of its nuchal counterpart. We present 2 cases of axillary cystic lymphangiomas that were diagnosed on prenatal sonography. In 1 case, prenatal sonography showed a multilocular, large cystic mass on the fetal left side, in the area of the lower chest and upper abdomen. The mass extended from at least the level of the umbilicus up to the neck but did not involve the neck. In the second case, prenatal sonography showed a multilocular, septate axillary cystic lymphangioma external to the chest with no flow on Doppler sonography. Follow‐up sonography revealed normal fetal growth and enlargement of the cystic mass surrounding the left humerus. Both infants were delivered without complications and have been managed conservatively.

Central hemodynamic effects of oxytocin and interaction with magnesium and pregnancy in the isolated perfused rat heart

OBJECTIVE Our purpose was to determine the cardiac effects of oxytocin in the isolated perfused rat heart model and to see whether pregnancy or pharmacologic levels of magnesium modifies the hormones action. STUDY DESIGN Hearts were excised from 30 female Sprague-Dawley rats (15 pregnant, 15 nonpregnant) and attached to a Langendorfs apparatus. Heart rate, left ventricular systolic pressure, and contractility were measured. Hearts were exposed serially to 2, 4, and 6 mU/ml concentrations of oxytocin. The experiment was repeated in 15 pregnant animals at a magnesium level of 5 mEq/L. RESULTS Hearts from pregnant rats had lower heart rates than did hearts from nonpregnant animals. Oxytocin exposure diminished heart rate but increased left ventricular systolic pressure and contractility in a dose-dependent manner. Pregnancy did not alter this response. Magnesium levels of 5 mEq/L reversed the effects of oxytocin on contractility and left ventricular systolic pressure. CONCLUSION Oxytocin is a negative chronotropic and positive inotropic agent in hearts from pregnant and nonpregnant rats. Magnesium reserves the positive inotropic effects of oxytocin.

Placental pathology in maternal and neonatal myeloproliferative disorders

TV is a 31-year-old multipara who presented with a left groin mass of 3 months’ duration concurrent with pregnancy. Prior surgical exploration had identified an immature malignancy consistent with a granulocytic sarcoma. Pregnancy progressed to 34 weeks, during which the patient continued to struggle with an open, necrotic, and malignantly infiltrated groin wound. Vaginal delivery of a healthy infant occurred at 34 weeks. Antepartum, excision of the groin mass to the level of the deep inguinal canal was accomplished. The specimen showed a hematolymphoid malignancy with gene rearrangement and monoclonal antibody typing consistent with a true histiocytic lymphoma. Computed tomography scan to complete staging indicated no active disease in the chest, moderate periaortic lympadenopathy, and a persistent 10 3 6 3 7 cm left inguinal mass. Postoperatively, the patient developed overwhelming sepsis along with a massive pulmonary embolism and died. Postmortem examination showed widely disseminated histiocytic lymphoma. KR is a 35-year-old secundagravida who was admitted for worsening fetal hydrops. An ultrasound obtained at 32 weeks demonstrated polyhydramnios, a large pericardial effusion, midline cystic dilation of the central nervous system, and hepatosplenomegaly. Fetal echocardiography showed tetralogy of Fallot. Despite a prolonged hospitalization and evaluation, the etiology of the fetal condition remained unclear. A cesarean delivery was performed at 35 weeks for fetal distress. Phenotype was consistent with trisomy 21. Cord blood gases were within the normal range. The initial neonatal leukocyte count was 224,000 with a peripheral smear showing an acute myeloid leukemia with megakaryocytic and erythroid markers. The leukocytosis resolved to a normal level without chemotherapy. Karyotype confirmed Down syndrome.

Antenatal doppler diagnosis of fetal ovarian torsion.

A 35-year-old woman, gravida 2, para 0-0-1-0, was referred for comprehensive prenatal ultrasound examination at 33 weeks’ gestation when a fetal abdominal mass was noted during a limited office ultrasound. Real-time sonography showed composite biometry consistent with a 33.2-week-old phenotypically female fetus with a complex cystic mass 4.2 3 4.8 3 4.8 cm in the lower abdomen, situated between the left kidney and bladder. The gray-scale appearance of the mass was consistent with ovarian parenchyma and a complex cyst. Color Doppler imaging did not show any flow within the mass, leading to a diagnosis of fetal ovarian torsion. Repeat ultrasound 3 weeks later showed a persistent left abdominal mass in the fetus that was unchanged in size, echo texture, or Doppler signal. Interval growth of the fetus was appropriate. Amniotic fluid volume and umbilical artery tracings were within normal limits. Postnatal surgery was planned. The woman labored spontaneously at 37 weeks’ gestation and delivered a 3075-g girl with Apgar scores of 8 and 9 at 1 and 5 minutes, respectively. On the fourth day of life, pelvic ultrasound of the neonate showed a complex cystic mass 5.6 3 3.4 3 5.2 cm in the left abdomen, which was more liquefied than on prenatal studies, and contained large amounts of dependent layering material and swirling debris. No flow was observed on Doppler imaging. The ovary was removed surgically, and ovarian torsion was confirmed intraoperatively and pathologically. Comment

Romano Ward Syndrome in Pregnancy

Romano-Ward syndrome is an unusual and potentially devastating disorder manifested by prolongation of the QT interval. Persons with this syndrome are at risk for sudden death from ventricular dysrhythmis. A case of a gravid woman with the disorder is presented

Stabilizing the Mother-Infant Dyad for Better Outcomes from OB to FM Caring for Patients with Perinatal Opioid Use Disorder through the 4th Trimester

A 24-year-old woman in her 2nd pregnancy presents for care. Standard screening questions prompt her to disclose illicit use of the opioid buprenorphine, which she obtained in the community to avoid heroin use. Her ultrasound reveals a 32-week gestation; patient is referred to our combined substance use treatment and obstetrics clinic where medically supervised prescription buprenorphine is initiated, as part of medication-assisted treatment for opioid use disorder in pregnancy. She volunteers that she did not seek care sooner due to fear of judgment and apprehension that she will lose her children due to her substance use. Our integrated team of clinical and behavioral health providers, familiar with these intertwined clinical and social dynamics, is briefed. A behavioral health clinician and a neonatal abstinence syndrome educator from the local hospital system see the patient together and discuss the hospital processes that will occur with admission for active labor. The patient continues prenatal care and medication-assisted treatment checks and meets providers from the nearby family health center who can continue medication-assisted treatment after postpartum discharge. Maintaining the mother-infant dyad, when safe, should be the goal of perinatal substance use treatment. These interactions with multiple clinical and community supports provide opportunities for engagement with both obstetrics and substance use services. Building trusting relationships will assist the patient in the transitions of care common to substance use in pregnancy and ensure continued support through the immediate postpartum months (often called the 4th trimester). Opioid/substance use disorders are present in your waiting room. Are you…

Prenatal Diagnosis of Exenceplhaly

Exencephaly is a rare congenital anomaly, thought to be a precursor of anencephaly. Like anencephaly, this abnormality is characterized by absence of the cranial vault above the orbits. However, unlike anencephaly, discrete, sometimes disorganized, brain tissue can be identified above the cranial defect. In this article, the authors report a case of exencephaly diagnosed prenatally during transvaginal ultrasound examination, with anatomic and pathologic correlation.