Rubin Raju

Congenital hernia of cord: an often misdiagnosed entity

Congenital hernia of the cord, also known as umbilical cord hernia, is an often misdiagnosed and under-reported entity, easily confused with a small omphalocele. It is different from postnatally diagnosed umbilical hernias and is believed to arise from persistent physiological mid-gut herniation. Its incidence is estimated to be 1 in 5000. Unlike an omphalocele, it is considered benign and is not linked with chromosomal anomalies. It has been loosely associated with intestinal anomalies, suggesting the need for a complete fetal anatomical ultrasound evaluation. We present a case of a fetal umbilical cord hernia diagnosed in a 28-year-old woman at 21 weeks gestation. The antenatal and intrapartum courses were uncomplicated. It was misdiagnosed postnatally as a small omphalocele, causing unwarranted anxiety in the parents. Increased awareness and knowledge of such an entity among health professionals is important to prevent unwarranted anxiety from misdiagnosis, and inadvertent bowel injury during cord clamping at delivery.

The Effect of the 39-Week Initiative on Intrauterine Demise: One Hospital's Experience [254].

INTRODUCTION: Published studies have shown mixed results regarding the risks of intrauterine fetal demise after implementation of guidelines for reduction of nonmedically indicated deliveries before 39 weeks of gestation. Our objective was to describe the variation in rates of intrauterine fetal demise in a high-risk patient population after implementation of guidelines eliminating nonmedically indicated deliveries before 39 weeks of gestation. METHOD: This was a retrospective chart review of patients with intrauterine fetal demise delivering at or beyond 20 weeks of gestation or birth weight 350 g or more when the gestational age was unknown between March 4, 2012, and July 31, 2014, at Hurley Medical Center in Flint, Michigan. RESULTS: A total of 6,561 deliveries were performed during the study period. Group 1: 2,846 deliveries before implementation of the guidelines with 16 cases of intrauterine fetal demise. Group 2: 3,715 deliveries after the guidelines with 29 cases of intrauterine fetal demise. Despite a small sample size, the most concerning observation is that the rate of intrauterine fetal demise between 37 and 39 weeks of gestation increased from 0.35 to 1.35 per 1,000 births after implementation of the guidelines. CONCLUSION: In our institute, the rate of stillbirth has increased since implementation of and strict adherence to guidelines for the elimination of elective induction of labor or cesarean delivery before 39 weeks of gestation were instituted. This is a disturbing trend that needs further evaluation, especially in medical centers caring for a high-risk pool of patients for whom all medical indications are not covered by the lists of approved indications.

The importance of fetal sex determination

The executive summary statement of a Joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal–Fetal Medicine, American Institute of Ultrasound in Medicine, American College of Obstetricians and Gynecologists, American College of Radiology, Society for Pediatric Radiology, and Society of Radiologists in Ultrasound Fetal Imaging Workshop reported that screening the fetal genitalia should be a part of the standard fetal sonographic examination only in cases of multiple gestations and when medically indicated. We report a case of a 39-year-old pregnant woman, G2P0Sab1, who was referred at 31 weeks and 3 days’ gestation to our Maternal– Fetal Medicine unit for consultation on her pregnancy, which was complicated by suspected fetal skeletal dysplasia and intrauterine growth restriction on the basis of sonography performed outside our unit. The patient had declined prenatal diagnosis and sonographic assessment for fetal sex earlier in her pregnancy. The sonograms obtained in our unit confirmed the diagnosis of severe intrauterine growth restriction, but skeletal dysplasia was not suggested. The sex of the fetus was not assessed, in accord with the patient’s request. Cesarean delivery was performed at 31 weeks and 6 days’ gestation for non-reassuring fetal testing and abnormal follow-up Doppler imaging of the umbilical cord. The neonate was small for its gestational age, weighing 1,120 grams. Most notably, the neonate was found to have abnormal genitalia and was diagnosed with a disorder of sex development (Figure 1). The parents experienced emotional distress in having to deal with the uncertainty about the infant’s sexual identity. Both obstetric and neonatal care providers were as stunned as the parents. The patient was discharged home on post partum day 4 without knowing the infant’s sex; the parents were thus unable to announce the sex to family and friends, which was extremely distressing. Chromosomal analysis, hormonal analysis, and radiologic studies eventually showed a male fetus with severe hypospadias and undescended testes. The sex of a neonate is very important to parents and families. This is often the first question asked after its delivery if the sex was unknown beforehand. Fetal sex carries both psychological and social implications. To parents, the prenatal knowledge of fetal sex is as important if not more important than screening for Trisomy 21. Of note, screening for Trisomy 21 is common and part of the standard of care in the United States. Moreover, cell-free fetal DNA screening is becoming more common, even in low-risk women; thus, if the sex is determined by that testing, confirmatory scanning for the genitalia should be warranted during the anatomy scan. Thus, more directed guidelines for the assessment of fetal sex during prenatal sonographic examination should be considered for pregnant patients in the United States. In conclusion, we propose that FIGURE 1. The neonate’s genitalia post partum day 2.

Should Prophylactic Anticoagulation Be Considered with Large Uterine Leiomyoma? A Case Series and Literature Review

Introduction. Uterine leiomyomas, also called uterine fibroids or myomas, are the most common pelvic tumors in women. They are very rarely the cause of acute complications. However, when complications occur they cause significant morbidity and mortality. Thromboembolic disease has been described as a rare complication of uterine leiomyomas. DVT is a serious illness, sometimes causing death due to acute PE. Cases. We report a case series of 3 patients with thromboembolic disease associated with uterine leiomyoma at Hurley Medical Center, Flint, Michigan, during 2015 and conduct a literature review on the topic. A literature search was conducted using Medline, PubMed, and PMC databases from 1966 to 2015. Conclusion. The uterine leiomyoma is a very rare cause of PE and only few cases have been reported. DVT secondary to uterine leiomyoma should be considered in a female presenting with abdominal mass and pelvic pressure, if there is no clear common cause for her symptoms. Thromboembolic disease secondary to large uterine leiomyoma should be treated with acute stabilization and then hysterectomy. Prophylactic anticoagulation would be beneficial for lowering the risk of VTE in patients with large uterine leiomyoma.