Kathy B. Porter

THE PRENATAL DIAGNOSIS OF CLOACAL EXSTROPHY

PURPOSE We assess and clarify diagnostic features for making the prenatal diagnosis of cloacal exstrophy. MATERIALS AND METHODS We evaluated 9 patients born with cloacal exstrophy at our institutions (2 prospectively and 7 retrospectively) for diagnostic features on prenatal ultrasound studies. We also thoroughly reviewed the literature on 13 previous prenatally diagnosed cloacal exstrophy cases. Diagnostic criteria were assessed by combining the findings in our patients and those in previous reports. RESULTS Of the 22 patients with prenatal ultrasound studies and cloacal exstrophy whom we analyzed 1 of our 9 and 2 in the literature had a cloacal membrane that persisted at 22 weeks of gestation. Major ultrasound criteria for diagnosing cloacal exstrophy prenatally are nonvisualization of the bladder, a large midline infraumbilical anterior wall defect or cystic anterior wall structure (persistent cloacal membrane), omphalocele and lumbosacral anomalies. Seven less frequent or minor criteria include lower extremity defects, renal anomalies, ascites, widened pubic arches, a narrow thorax, hydrocephalus and 1 umbilical artery. CONCLUSIONS We propose major and minor criteria to assist in the prenatal diagnosis of cloacal exstrophy. Despite these major and minor criteria the certainty of establishing a prenatal diagnosis remains challenging. Persistence of the cloacal membrane beyond the first trimester in 1 patient was an exception to the classic concept of cloacal exstrophy embryogenesis. An accurate prenatal diagnosis requires validation of these criteria by further correlation of prenatal and postnatal observations.

Blunt versus sharp expansion of the uterine incision in low-segment transverse cesarean section

OBJECTIVE Both blunt and sharp expansion of the initial incision at transverse cervical cesarean birth have advocates, on the basis of theoretic concerns. We sought to study the incidence of complications, including unintended extension, associated with each of these methods by comparison by means of a prospective, randomized study. STUDY DESIGN Women scheduled to undergo nonemergency cesarean birth were assigned to blunt and sharp expansion groups. Other than expansion of the incision, standard technique was used throughout surgery. Data, including length and number of unintended extensions, vessel laceration, and length of surgery, were recorded immediately. RESULTS The blunt (n = 139) and sharp (n = 147) expansion groups were similar with regard to indication and duration of labor. No difference in the incidence of unintended extension, postoperative endometritis, duration of surgery, or estimated blood loss was noted. The frequency of unintended extension (1.4%, 15.5%, and 35.0% for no labor and first and second stages, respectively) correlated with the stage of labor. CONCLUSION Blunt and sharp expansions of the uterine incision are equivalent in ease and safety.

Effects of raloxifene in a guinea pig model for leiomyomas

OBJECTIVE Chronic exposure of oophorectomized guinea pigs to 17beta-estradiol causes leiomyoma formation. Our aims were to determine whether these leiomyomas can become estradiol independent after exposure to estradiol and if raloxifene inhibits leiomyoma growth when given concomitantly with estradiol. STUDY DESIGN To induce leiomyoma development, 6 oophorectomized animals received two estradiol implants for 140 days. Next, the estradiol implants were replaced with empty implants in 3 animals, whereas the other 3 received 2 new estradiol implants and raloxifene given per os 10 mg/kg per day for 60 days. Tumor size was monitored biweekly by ultrasonography. RESULTS On estradiol removal, abdominal wall leiomyomas regressed within 15 to 30 days; when estradiol implants were reintroduced, leiomyomas redeveloped. Within 30 days on raloxifene, all abdominal leiomyomas (n = 9) regressed as determined by ultrasonography and verified at laparotomy. Serum raloxifene and estradiol levels were 432 +/- 46 pg/mL and 78 +/- 13 pg/mL (mean +/- SEM, n = 3), respectively, after 60 days of treatment. CONCLUSIONS Leiomyomas did not become estradiol independent, even after long exposure to estradiol; ultrasonography allowed frequent, noninvasive assessment of leiomyoma size, and raloxifene rapidly regressed leiomyomas in this animal model.

The effect of magnesium sulfate on bleeding time in pregnancy.

OBJECTIVE The bleeding time is one of the most commonly used diagnostic tests to evaluate platelet-related hemorrhagic disorders. Magnesium has been shown in vitro to be a platelet antiaggregant. This study was conducted to evaluate the hypothesis that magnesium sulfate has no effect on the template bleeding time. STUDY DESIGN The study group consisted of 24 women who required magnesium sulfate in pregnancy. A blood cell count, platelet count, magnesium level, bleeding time, and mean arterial pressure were obtained before and 2 hours after magnesium sulfate infusion. Magnesium sulfate was infused beginning with a 6 gm intravenous bolus followed by 2 gm/hr. A template bleeding time was performed with a Simplate-II (Organon Teknika, Durham, N.C.) device. Two of the authors performed all the bleeding times. Data were analyzed with a paired t test and Wilcoxon rank test. RESULTS Fifteen (63%) patients received magnesium sulfate for tocolysis or before external cephalic version and nine (37%) for preeclampsia prophylaxis. No differences were found between the normotensive and hypertensive groups regarding maternal age, gestational age, initial bleeding time, or platelet count. Analysis of the entire study group revealed a prolongation of the bleeding time after magnesium sulfate (5.7 +/- 1.8 vs 6.6 +/- 1.9 minutes, p < 0.05); a lowering of the mean arterial pressure (p < 0.05), and a rise in the magnesium level (p < 0.05). Four patients (16.7%) had a postmagnesium bleeding time > 9 minutes. CONCLUSION Magnesium sulfate appears to prolong the bleeding time in pregnancy. The clinical significance remains to be determined.

Successful pregnancy after a liver transplant

The literature contains limited reports on successful pregnancy outcomes after a liver transplant. We report an uncomplicated pregnancy and delivery in a patient 35 months after liver transplantation because of chronic active hepatitis with resultant liver failure secondary to non-A non-B hepatitis.

Fetal Abdominal Hyperechoic Mass: Diagnosis and Management

In the last 2 years, we have had the opportunity to follow 12 cases diagnosed with hyperechoic abdominal masses. Four of the cases ended with a fetal demise, while 7 resulted in the birth of an anomalous or medically ill neonate. Only 1 case has shown spontaneous resolution of the hyperechoic mass with the birth of a normal neonate. The in utero diagnosis of a hyperechoic abdominal mass should encourage the clinician to further investigation since the differential diagnosis is quite diverse. Appropriate counselling for the patient is a necessary part of prenatal care.

Surgical debridement of necrotizing endomyometritis after cesarean delivery.

A 21-year-old black woman, gravida 2, para 1-0-0-1, presented in labor at 39 weeks’ gestation with active recurrent genital herpes and intact membranes. A 3725-g male infant was delivered by primary low transverse cesarean (through a Pfannenstiel skin incision). The patient was given cefazolin 2 g for prophylaxis. The uterus was closed using standard twolayer technique. The postoperative course was complicated by recurrent temperature elevations to 104°F and a paralytic ileus. Physical examination was consistent with endometritis. The patient was treated with 1.5 mg/kg (2 mg/kg load) of gentamicin every 8 hours and 900 mg of clindamycin every 8 hours. After 48 hours, 2 g of ampicillin every 6 hours and 5 mg/kg intravenously of acyclovir every 8 hours were added. A computed tomographic scan of the abdomen and pelvis on day 5 showed only free fluid, dilated loops of bowel consistent with paralytic ileus, and left lung base infiltrate. Hyperalimentation was initiated on day 5 secondary to prolonged ileus. For presumed septic pelvic thrombophlebitis, heparin was titrated to partial thromboplastin time of 1.5 to 2 times normal and was administered for 24 hours with no response. Results of blood cultures performed twice were negative. On day 8 her white blood cell count was 44 3 10 per microliter and her abdominal examination indicated worsening condition. On exploration, 8 L of yellow-green, nonmalodorous peritoneal fluid was removed and cultured. A fibrinous exudate was found throughout the abdomen, with no evidence of perforated viscus or localized abscess. A 2 3 2 3 1-cm full thickness area of the lower uterine segment appeared necrotic and was resected until viable-appearing myometrium bled. The uterine defect was closed in a single layer. After closure of the rectus fascia, the incision was left open. Culture results from the uterine debridement revealed Group B Streptococcus and S Aureus, sensitive to clindamycin. Pathology results showed inflammation and microabscesses adjacent to the resected normal myometrium, consistent with necrotizing endomyometritis. Postoperatively, antibiotics were changed to 2.5 million units of penicillin every 4 hours, and 900 mg of clindamycin every 8 hours, and she did well. Following delayed abdominal wound closure on day 8, she was discharged.

Computer Processed Electroencephalogram Signals Compared to Conventional EEG Signals in Preeclamptics

Monitors that use computer processed EEG signals have been developed to simplify recognition and interpretation of EEG changes. The information from one of these monitors was compared with signals obtained by simultaneous conventional EEG recordings in eight awake preeclamptics. All eight of the processed tracings were read as abnormal, while only one of the 16 channel conventional EEG recordings was abnormal. We conclude that this particular monitor will not be beneficial for assessing continuous brainwave activity in awake/drowsy preeclamptic women.