Yavuz Ceylan

Perinatal outcomes in severe preeclampsia-eclampsia with and without HELLP syndrome.

Objective: Our purpose was to find out and compare perinatal outcomes in pregnancies complicated by severe preeclampsia-eclampsia with and without HELLP syndrome. Methods: Clinical and laboratory findings, and perinatal-neonatal outcomes of all pregnants with severe preeclampsia, eclampsia and HELLP have been prospectively recorded. Results were compared by means of Student’s t test, χ2 analysis and Fisher’s exact test as appropriate. Results: Among 367 consecutive severe preeclampsia, 106 (29%) had HELLP syndrome, 261 (71%) had severe preeclampsia and eclampsia. Mean gestational age and birth weight at delivery in severe preeclampsia without HELLP syndrome and in HELLP syndrome were 34.1 ± 6.1 vs. 33.0 ± 5.8 weeks (p = 0.119) and 1,886 ± 764 vs. 1,724 ± 776 g (p = 0.063), respectively. Comparing overall fetal mortality (4.6 vs. 10.3%, p = 0.009) and perinatal mortality (8.0% vs. 16.8%, p = 0.026) in severe preeclampsia-eclampsia and HELLP syndrome, respectively, there were statistically significant differences. But when analyses were performed according to gestational age before and after 32nd gestational week, the difference of perinatal mortality between the two groups was non-significant (p = 0.644 and p = 0.250), suggesting borderline difference. The most common contributing factor for fetal death after 32nd week was due to abruptio placenta without prenatal follow-up. Neonatal morbidity and neonatal mortality (4.8 vs. 6.3%, p = 0.905) in severe preeclampsia-eclampsia and HELLP syndrome respectively were similar and the difference was statistically nonsignificant. Conclusions: Perinatal mortality and neonatal morbidity-mortality according to gestational age before and after the 32nd week were similar in HELLP syndrome compared with severe preeclampsia-eclampsia without HELLP but overall fetal mortality was higher in HELLP syndrome with no regular prenatal care.

Perinatal Outcomes of Twin Pregnancies Discordant for Major Fetal Anomalies

Objective: The aim of this study was to determine perinatal outcomes of twin pregnancies discordant for a major fetal anomaly and to compare with twins without anomaly. Methods: All twin pregnancies admitted or referred to the maternal-fetal unit were prospectively entered into a computer database. Chorionicity, fetal anomaly, mean gestational age at delivery, birth weight and perinatal survival rate were reviewed. Main Outcome Measures: Mean gestational age at delivery, birth weight and perinatal survival rate of twins with and without anomaly. Results: There were 48 cases of monochorionic diamniotic (MCDA), 2 cases of monochorionic monoamniotic (MCMA) and 217 twins with dichorionic (DC) placentation. Out of 267 twin pregnancies, there were 17 (6.3%) twins with fetal anomaly. Twins discordant for a major fetal anomaly were diagnosed in 13 cases (4.8%). We observed 3 cases with MCDA and 10 cases with DC placentation and the incidence of discordance for a major fetal anomaly as 4.6% (10/217) in DC and 6.0% (3/50) in MC twin pregnancies. We identified 8 cases (62%) with craniospinal, 2 (15%) with gastrointestinal, 2 (15%) with urinary system, and 1 case (8%) with both craniospinal and gastrointestinal anomalies. There were significant differences between the normal co-twin of the major anomaly group (n = 13) and twins without anomaly group (n = 235) in mean gestational age at delivery (32 vs. 34 weeks; p = 0.029), mean birth weight (1,640 vs. 2,030 g; p = 0.022) and perinatal survival rate (69.2 vs. 91.1%; p = 0.018), respectively. Conclusion: The presence of a fetus with a major anomaly in a twin gestation increases the risk of preterm delivery, low birth weight and perinatal mortality of the normal co-twin.

Uterine rupture associated with misoprostol labor induction in women with previous cesarean delivery

OBJECTIVE To review our experience with uterine rupture in patients undergoing a trial of labor with a history of previous cesarean delivery in which labor was induced with misoprostol. STUDY DESIGN A retrospective chart review was used to select patients who underwent induction of labor with misoprostol during the period from February 1999 to June 2002. Women with a history of cesarean delivery were retrospectively compared with those without uterine scarring. RESULTS Uterine rupture occurred in 4 of 41 patients with previous cesarean delivery who had labor induced with misoprostol. The rate of uterine rupture (9.7%) was significantly higher in patients with a previous cesarean delivery (P<0.001). No uterine rupture occurred in 50 patients without uterine scarring. Women with a history of cesarean delivery were more likely to have oxytocin augmentation than those without uterine scarring (41% versus 20%; P=0.037). CONCLUSION Misoprostol induction of labor increases the risk of uterine rupture in women with a history of cesarean delivery.

Maternal and Fetal Outcomes in HELLP Syndrome Complicated with Acute Renal Failure

Objective. This study reviews maternal and fetal outcomes in HELLP syndrome complicated with acute renal failure (ARF), and compares clinical and laboratory findings of the cases of HELLP syndrome that did not develop ARF. Materials and Methods. All pregnant women with hypertensive disorders admitted or referred to the maternal and fetal unit were recorded into a perinatal database between January 15, 2002 and September 15, 2003. During the study period, out of 615 cases of hypertensive pregnancy, we followed and delivered 347 cases of severe preeclampsia, of them 132 cases were diagnosed as HELLP syndrome. ARF was defined as creatinine level ≥ 1.2 mg/dL and/or oliguria < 400 mL/24 hr. The cases were divided into three groups on the basis of the highest creatinine level recorded during hospitalization: creatinine < 1.2 mg/dL, creatinine ≥ 1.2 to 2.0 mg/dL, and creatinine ≥ 2.0 mg/dL. Statistical comparisons were performed by Student t test, X2 analysis, and Fishers Exact test as appropriate. The value of P < 0.05 was considered significant. Results. ARF developed in 8.9% (n:31) of severe preeclampsia (n:347); of them, 15 (4.3%) cases were nonoliguric, and all had mildly elevated creatinine levels between 1.2 and 1.9 mg/dL. Moderately elevated creatinine levels were 2 to 3.9 mg/dL in 10 cases, and severely elevated creatinine levels were 4 to 8.4 mg/dL in 6 cases, for a total of 16 (4.6%) cases; creatinine levels were ≥ 2.0 mg/dL (range: 2.0–8.4 mg/dL). HELLP syndrome was the most frequent cause of ARF, 64.5% (n:20/31), and was observed in 15% (n:20) of 132 cases of HELLP syndrome. Fourteen (88%) of 16 cases that had oliguria and creatinine levels ≥ 2 mg/dL were detected in HELLP syndrome (n:14/132; 10.6%). Major maternal complications in HELLP syndrome with ARF and creatinine level ≥ 2 mg/dL in the study group were abruptio placentae (42.8%; n:6/14), incisional hematoma (21%; n:3/14), pulmonary edema (14%; n:2/14), cesarean hysterectomy (7%; n:1/14), and dialysis (50%; n:7/14). There was no maternal mortality. All patients complicated with ARF were discharged without renal impairment. Perinatal mortality was 26.1% in the cases of HELLP syndrome with ARF‐creatinine ≥ 1.2 mg/dL and further increased to 37.5% when creatinine levels were above 2.0 mg/dL, compared with 11.8% in the cases having creatinine < 2.0 mg/dL, and the difference was statistically significant (p:.007). Conclusions. The most contributing factors leading to ARF in HELLP syndrome were abruptio placentae and HELLP syndrome complicated with ARF, particularly, oliguric ARF has relatively higher maternal complications and perinatal mortality.

Natural History of 11 Cases of Twin-twin Transfusion Syndrome Without Intervention

The natural history of 11 cases of twin-twin transfusion syndrome (TTTS) in monochorionic diamniotic (MCDA) twin pregnancies has been reviewed. Seven cases before 28 weeks and four pregnancies after 28 weeks had been followed up without intervention. Eight cases had premature uterine contractions. All seven pregnancies before 28 weeks aborted, leading to a 100% mortality rate. After 28 weeks all mothers delivered live births. The diagnosis of TTTS before 28 weeks, and with premature uterine contraction, seems to be a poor prognostic sign.

Multidisciplinary approach in cystic hygroma: Prenatal diagnosis, outcome, and postnatal follow up

Background:  The aim of the present study was to determine prenatal follow up and clinical outcome in fetuses born with cystic hygroma.

The outcome of twin pregnancies complicated by single fetal death after 20 weeks of gestation.

A retrospective study involving 972 twin births was conducted to evaluate the maternal and fetal outcomes of twin pregnancies complicated by single fetal death. The incidence of single fetal death in twin pregnancies after 20 weeks was 3.3%. Preterm birth rates for 37 and 32 gestational weeks were 81.3% and 41.6% respectively. The median interval between the diagnosis of fetal death and the delivery was 11 days (range 1-27 days). Eighteen (56%) infants were delivered by cesarean and 14 (43%) vaginally. Twin-twin transfusion syndrome (TTTS) was the cause of single fetal death in 8 of 32 twin pregnancies (25%). Ten of the surviving co-twins were lost in the neonatal period (31.3%) and half of those neonatal deaths were due to TTTS. TTTS is the major contributor for perinatal mortality in same-sex twins complicated by single fetal death. The death of one twin in utero should not be the only indication for preterm delivery, and in case of severe prematurity with a stable intrauterine environment; expectant management may be advisable until fetal lung maturation ensues.

Prenatal diagnosis of 13q-syndrome in a fetus with dandy-walker malformation

BACKGROUND: Partial deletion of the long arm of the chromosome 13 is a rare chromosomal aberration and may present with microcephaly, colobomata, microphthalmia, distal limb and digital anomalies, cardiac defects, brain and urogenital malformations, anal atresia and growth restriction. CASE: We report such a case in 25th week of gestation referred for sonographic examination which revealed growth restriction, microcephaly, Dandy-Walker malformation, right microphthalmia, micrognathia, marked nuchal edema, four fingers–oligodactyly in feet and in hands with thumb aplasia and ambiguous genitalia. Chromosome analysis identified chromosome 13q deletion [46 XY del (13) (13q31.2/q32.1 → qter)]. Postmortem examination confirmed prenatal findings and showed aniridia, low-set ears, cryptorchidism, and anal atresia. CONCLUSION: Detection of Dandy-Walker malformation, microphthalmia, oligodactyly with thumb aplasia and growth restriction during prenatal ultrasonography should be a reminder of deletion of chromosome 13q and warrant cytogenetic analysis.

Preeclampsia Due to Fetal Non-immune Hydrops: Mirror Syndrome and Review of Literature

Objective. Mirror syndrome (Ballantynes syndrome) refers to the association of fetal hydrops and maternal preeclampsia. The aim of this study was to determine the relation and incidence between fetal hydrops and preeclampsia in our clinic. Methods. A retrospective review of patients associated with fetal hydrops and findings with preeclampsia was used. Seventy-five cases with single pregnancy and diagnoses with nonimmune hydrops fetalis were found. According to the data 4 cases were found related with preeclampsia. Results. Mirror syndrome is rarely encountered and underdiagnosed. We found a frequency of 5.3% (4 cases in 75 affected pregnancies) for single non-immune hydrops cases in which maternal hypertension occurred. Fetal outcome is depending on etiology and prognosis is mainly very low. Maternal symptoms and laboratory findings are resolving after intrauterine fetal death or delivery. Conclusion. Hydrops fetalis must be considered as a potential risk factor for preeclampsia. It is important that this clinical condition has a potential of about 5% for proceeding preeclampsia.

Membrane sweeping to induce labor in low-risk patients at term pregnancy: A randomised controlled trial

Objective. To evaluate the efficacy of membrane sweeping at initiation of labor induction in low-risk patients at term pregnancy (38–40 gestational weeks). Methods. This prospective study included 351 antenatal women who were randomly assigned to one of two groups: a sweeping of the membranes group (n = 181) and a no sweeping control group (n = 170). The primary outcome measure was the proportion of women who entered spontaneous labor within 1 week of entry into the study. Secondary outcome measures included mode of delivery and maternal and fetal complications. Results. Five patients (two in the sweeping group and three in the no sweeping group) were excluded from the study because of breech presentation at labor. There were no statistically significant differences between the two groups regarding maternal age, parity or Bishop score. The proportion of subjects who entered spontaneous labor before 41 weeks of gestation was significantly different between the two groups (p < 0.0001). The mode of delivery did not differ significantly between the groups and there was no statistically significant difference in maternal or fetal complications. Conclusions. Sweeping of membranes is a safe method to reduce the length of term in pregnancy and the incidence of prolonged gestation in a low-risk population. There is no evidence that sweeping the membranes increases the risk of maternal or neonatal adverse outcomes.