Walter J. Morales

Staging of twin-twin transfusion syndrome

OBJECTIVE:The purpose of this study was to evaluate the prognostic value of sonographic and clinical parameters to develop a staging classification of twin-twin transfusion syndrome (TTTS).STUDY DESIGN:Severe TTTS was defined as the presence of polyhydramnios (maximum vertical pocket of ≥8 cm) and oligohydramnios (maximum vertical pocket of ≤2 cm). Nonvisualization of the bladder in the donor twin (−BDT) and absence of presence of hydrops was also noted. The middle cerebral artery, umbilical artery, ductus venosus, and umbilical vein in both fetuses were assessed with pulsed Doppler. Critically abnormal Doppler studies (CADs) were defined as absent/reverse end-diastolic velocity in the umbilical artery, reverse flow in the ductus venosus, or pulsatile flow in the umbilical vein. TTTS was staged as follows: stage I, BDT still visible; stage II, BDT no longer visible, no CADs; stage III, CADs; stage IV, hydrops; stage V, demise of one or both twins. Laser photocoagulation of communicating vessels (LPCV) or umbilical cord ligation was performed depending on the severity of the condition. The study was approved by the Institutional Review Board of St. Joseph’s Hospital in Tampa and by the Fetal Therapy Board at Hutzel Hospital, Detroit, and all patients gave informed consent.RESULTS:A total of 80 of 108 referred patients met criteria for surgery, but only 65 were treated surgically: 48 with LPCV and 17 with umbilical cord ligation. Complete Doppler data were obtainable in 41 of 48 LPCV patients. Survival rates by stage for one or two fetuses were statistically different (χ-squared analysis = 12.9, df = 6, p = 0.044). Neither percent size discordance nor gestational age at diagnosis were predictive of outcome.CONCLUSION: Staging of TTTS using the proposed criteria has prognostic significance. This staging system may allow comparison of outcome data of TTTS with different treatment modalities.

Change in antibiotic resistance of group B streptococcus: impact on intrapartum management.

OBJECTIVE Intrapartum chemoprophylaxis has resulted in a significant reduction of group B Streptococcus neonatal infection. For penicillin-allergic patients, clindamycin or erythromycin is the recommended antibiotic. The purpose of this study was to establish any pattern of antibiotic resistance of group B streptococcal clinical isolates over the past 15 years. STUDY DESIGN Group B streptococcal isolates obtained from the lower genital tract were tested for sensitivity to ampicillin, penicillin, clindamycin, and erythromycin. The sensitivity of 100 group B streptococcal isolates retrieved in the period 1997-1998 was compared with that of 85 group B streptococcal isolates from 1980-1993. RESULTS From 1980-1993 group B streptococcal isolates were available for testing for antibiotic resistance along with 100 isolates from a second study period 1997-1998. Of the 100 group B streptococcal isolates from 1997-1998, 18 were resistant to erythromycin, of which 5 were also resistant to clindamycin, as compared with 1 of the 85 isolates from 1980-1993 that was resistant to erythromycin (P <.001). All the isolates were sensitive to ampicillin and penicillin. All 18 resistant strains from 1997-1998 were found to be sensitive to cephalothin. CONCLUSION Over the past 18 years there has been increased in vitro resistance of group B streptococci to both clindamycin and erythromycin. If other studies confirm these findings, modifications to the current Centers for Disease Control and Prevention recommendations may be necessary.

Treatment of iatrogenic previable premature rupture of membranes with intra-amniotic injection of platelets and cryoprecipitate (amniopatch): Preliminary experience

OBJECTIVE Our aim was to describe the treatment of iatrogenic previable premature rupture of membranes with the intra-amniotic injection of platelets and cryoprecipitate (amniopatch). STUDY DESIGN Patients with iatrogenic previable premature rupture of membranes and without evidence of intra-amniotic infection underwent transabdominal intra-amniotic injection of platelets and cryoprecipitate through a 22-gauge needle. The study was approved by the Institutional Review Board of St Josephs Hospital in Tampa, Florida, and all patients gave written informed consent. RESULTS Seven patients with iatrogenic preterm premature rupture of membranes underwent placement of an amniopatch. Membrane sealing was verifiable in 6 of 7 patients. Three patients had iatrogenic preterm premature rupture of membranes after operative fetoscopy, 3 cases were after genetic amniocentesis, and 1 was after diagnostic fetoscopy. Three pregnancies progressed well, with restoration of the amniotic fluid volume and no further leakage. Two patients had unexplained fetal death despite successful sealing. One case of bladder outlet obstruction had no further leakage, but oligohydramnios persisted and did not allow unequivocal documentation of sealing. One patient miscarried from twin-twin transfusion, but the amniotic cavity was sealed. CONCLUSIONS Iatrogenic preterm premature rupture of membranes can be treated effectively with an amniopatch. The technique is simple and does not require knowledge of the exact location of the defect. Unexpected fetal death from the procedure may be attributable to vasoactive effects of platelets or indigo carmine. Although the appropriate dose of platelets and cryoprecipitate needs to be established, the amniopatch may mean that iatrogenic preterm premature rupture of membranes no longer needs to be considered a devastating complication of pregnancy.

Efficacy and safety of indomethacin compared with magnesium sulfate in the management of preterm labor: A randomized study

OBJECTIVE Our purpose was to evaluate the relative efficacy and safety of indomethacin versus magnesium sulfate in the management of preterm labor in pregnancies < 32 weeks of gestation. STUDY DESIGN Eligible patients admitted with singleton pregnancies and idiopathic preterm labor between August 1988 and October 1989 were randomized by sealed envelopes to receive either indomethacin or intravenous magnesium sulfate. RESULTS Of 101 eligible patients 49 were randomized to receive indomethacin. The two study groups were similar in regard to a number of entry variables, including gestational age, cervical examination, and contraction frequency. Indomethacin was as effective as magnesium sulfate in delaying delivery > 48 hours, 90% versus 85%, and together with oral terbutaline in extending the gestation, 22.9 versus 22.7 days. Tocolysis with magnesium sulfate was discontinued in eight (15%) patients because of maternal side effects, in contrast to none in the indomethacin group, p < 0.05. CONCLUSION For gestations < 32 weeks indomethacin may be considered an appropriate alternative to magnesium sulfate as a first-time tocolytic agent.

Aggressive perinatal care for high-order multiple gestations: Does good perinatal outcome justify aggressive assisted reproductive techniques?

OBJECTIVE The purpose of this study was to determine the factors that must be considered for appropriate counseling of patients with high-order multiple gestations. STUDY DESIGN A retrospective chart review was carried out from all high-order multiple gestations that were managed by a single perinatology group from February 1993-June 1998. Twin pregnancies that did not result from fetal reduction procedures were used as a control group. RESULTS Clinical outcome data were analyzed from 9 quadruplet, 25 triplet, 19 reduced twin, and 24 nonreduced twin pregnancies. Women with quadruplet pregnancies were admitted more frequently at an early gestational age, the infants were delivered earlier, and the maternal and neonatal hospital days were longer than for triplet and reduced and nonreduced twin gestations. Triplet pregnancies had an earlier gestational age at delivery (32.3 vs 34.2 weeks), a higher incidence of preterm labor (87% vs 68%), and a higher percentage of neonatal intensive care unit admissions (94% vs 59%) than reduced twin gestations. Reduced twins were hospitalized longer (16.4 vs 9.8 days), were delivered earlier (34.2 vs 36.2 weeks), had a higher incidence of preterm labor (68% vs 29%), and had a greater percentage of neonatal intensive care unit admissions (59% vs 21%), a greater percentage of birth weight <1500 g, and a greater frequency of respiratory distress syndrome (16% vs 2%) than nonreduced twins. There was no difference in neonatal survival and neurologic morbidity when all groups were compared. CONCLUSION Although early delivery and prolonged (maternal and neonatal) hospitalization were common with quadruplets and triplets, maternal and neonatal outcomes were excellent. The decision for reduction from triplets to twins may not necessarily change pregnancy outcome but should still be discussed as an option for the parents. Continued efforts need to be made to reduce the overall number of iatrogenic high-order multiple gestations.

Transabdominal intra-amniotic endoscopic assessment of previable premature rupture of membranes.

OBJECTIVE Our purpose was to describe the endoscopic characteristics of the site of rupture in vivo in patients with spontaneous premature rupture of membranes. STUDY DESIGN Patients with preterm premature rupture of membranes between 16 and 26 weeks of gestation, without evidence of intra-amniotic infection, and with a normal karyotype underwent transabdominal endoscopic examination of the amniotic cavity. Subsequently, an amniopatch of a combination of platelets and cryoprecipitate to seal the membrane defect was administered. The study was approved by the Institutional Review Board of St. Josephs Hospital in Tampa, Florida, and all patients gave written informed consent. RESULTS Four patients underwent endoscopic examination and amniopatch administration; three had spontaneous preterm premature rupture of membranes, and in the other the membranes ruptured after an early amniocentesis. The location of the site of rupture was over the internal os in the 3 cases with spontaneous preterm premature rupture of membranes. This area was normal in the patient with iatrogenic preterm premature rupture of membranes. The longer the time between preterm premature rupture of membranes and fetoscopy, the larger and less defined was the site of rupture. The amniopatch restored amniotic integrity for a maximum of 72 hours. CONCLUSIONS This is the first in vivo endoscopic visualization of the site of spontaneous rupture of membranes from within the uterine cavity. The defect is located over the internal cervical os in patients with spontaneous preterm premature rupture of membranes. There appear to be time-related changes in the morphologic characteristics of the site of rupture. Endoscopic visualization of the site of rupture has the potential for improving our understanding of spontaneous preterm premature rupture of membranes and in the development of possible therapeutic alternatives.

In utero Diagnosis of Trichothiodystrophy by Endoscopically-Guided Fetal Eyebrow Biopsy

Objective: To describe the prenatal diagnosis of trichothiodystrophy (TTD) through endoscopically-guided fetal eyebrow biopsy. Materials and Methods: A 32-year-old patient, gravida 4, para 3, with a history of 2 previous infants affected with TTD was referred at 175/7 weeks for fetal hair biopsy. DNA repair studies had been normal in the previous children. Four 1-mm biopsies were obtained from the external aspect of the fetal eyebrows under direct endoscopic guidance. Fetal hair samples were assessed with polarized microscopy, electron microscopy, hematoxylin and eosin staining, and were also sent for analysis of sulfur content (cystine levels). Results: The fetal eyebrows were the only adequate source of hair in the early second trimester. The biopsy samples yielded adequate material for all tests. Polarized microscopy showed characteristic banding patterns, but trichoschisis was not apparent. Cystine levels (19 μmol/l) in the biopsy sample were significantly lower than an age-matched (fresh spontaneous abortion) control (368 μmol/l). Conclusion: Prenatal diagnosis of TTD is possible in the second trimester through endoscopically-guided eyebrow biopsy. An adequate amount of hair is present in the eyebrows by then, and the disease is already manifest. Analysis of sulfur content of the hair samples is preferred over polarized or electron microscopy, as many classic microscopic findings of TTD may not be present in the early second trimester.