Actively continued twin pregnancy with intrauterine death of one fetus

A case of twin pregnancy with intrauterine death of one fetus in the 28 th week of pregnancy been described. The pregnancy was actively continued. The following procedure was introduced: 1. Tocolysis, 2. Drugs accelerating lung maturation of the alive fetus, 3. Antinfectious and anticoagulopathy prophylaxis, 4. Special care of the mother and the alive fetus. In the 30 th week of pregnancy spontaneus labor occurred "per via naturales". The macerated dead fetus and the alive premature newborn were born. The baby was charged home in good condition in the 45 th day after delivery.     

Vaginal lever pessary in patients with multiple gestation, preterm labor and low fetal station. A report of three cases

BACKGROUND: The vaginal pessary has been utilized previously in patients with cervical incompetence, resulting in improvement in pregnancy outcome. The mechanical advantages generated by the vaginal lever pessary could theoretically be applied to patients in preterm labor with low station of the presenting part to prevent cervical dilatation. CASES: One patient with twins and two with triplet pregnancies presented in preterm labor with advanced cervical dilatation and low fetal station. They were treated with tocolytic drugs, and a vaginal lever pessary was placed. The gestational age at delivery was delayed with the addition of the vaginal pessary. Based on previous experience with these difficult cases, it was judged that the use of the pessary achieved a delay in delivery that would not have occurred without the device. CONCLUSION: Vaginal pessaries can be used as mechanical adjuvants in the treatment of preterm labor. These devices work by altering the pressure dynamics on the cervix and lower uterine segment. They may also help limit cervical change by preventing engagement of the presenting part into the maternal pelvis. In these cases, a vaginal pessary appears to be beneficial in delaying delivery in multiple gestations presenting with advanced cervical dilatation and low station of the presenting part.     

Cervical assessment by magnetic resonance imaging--its relationship to gestational age and interval to delivery

The aim of this cross-sectional study was to assess the uterine cervix in late pregnancy, using MRI, and to study its relationship to the gestational age and the time interval to delivery. 91 women with a singleton cephalic presenting fetus had MRI of the pelvis between 35 and 41 weeks. All had had one prior lower segment Caesarean section and no history of prior vaginal delivery. The cervical length, internal and external os diameter, cervical signal intensity and the angulation of the cervix with the cephalocaudal axis were measured on sagittal T2 weighted images and correlated with the gestational age and the interval from the MRI examination to delivery. It was found that the signal intensity of the cervical stroma increased with the gestational age. A higher signal intensity in the cervical stroma was associated with a shorter time interval to delivery. Deliveries after 40 weeks tended to occur more commonly in those with lower signal intensity in the cervical stroma and also in those with a smaller external os diameter. It is concluded that cervical softening as assessed on MRI correlated with gestational age and the time interval to delivery.     

From SA to UK: a profile of South African qualified dentists registered with the General Dental Council

Generally, it is preferable to tocolyze patients with idiopathic preterm labor (PTL). Little information is available about ultimate outcomes after successful tocolysis. Our objective is to evaluate the relationship between cervical change after the initiation of tocolysis and the delay in time to delivery in patients with preterm labor. A historical analysis of all patients with successful tocolysis after PTL between January 1992 and December 1993 was undertaken. The patients were then placed in one of three categories (regression, unchanged, or progression) based on cervical change after the initiation of tocolysis. Various demographic pregnancy characteristics and pregnancy outcome data were analyzed. One hundred and twenty-six patients had successful tocolysis and met the admission criteria. Patients who had cervical progression had shorter delay to delivery, delivered at an earlier gestational age (31.7 weeks compared to 34.0 and 34.1 weeks, respectively, p < 0.05), and were more likely to deliver before 35 weeks (88% compared to 50.0 and 55.0%, respectively, p < 0.05). Also, neonates remained in the hospital longer and were more likely to have respiratory distress syndrome when compared to the other two groups. Patients who had cervical progression after the initiation of tocolysis are more likely to deliver prematurely, had a shorter delay to delivery, and delivered lower birth weight infants than did patients whose cervix regressed or remained unchanged. In our population, patients who had successful tocolysis had a preterm delivery rate of 59.5% before the 35th week of gestation.     

Delayed-interval delivery in a quadruplet pregnancy after intrauterine death of a partial molar pregnancy and preterm delivery. A case report

BACKGROUND: Delayed-interval delivery is infrequent in twin gestation and more rare in triplet and quadruplet gestation. Coexistence of a triploid pregnancy with a normal fetus has not previously been reported to have resulted in survival of the normal fetus. CASE: A 26-year-old woman, gravida 2, para 0-0-1-0, was diagnosed with a quadruplet pregnancy. At 16 1/2 weeks' gestation she developed preeclampsia and severe hyperemesis. Ultrasound was consistent with partial molar pregnancy in quadruplet D. Quadruplet D died in utero, and the preeclampsia and hyperemesis resolved. At 19 5/7 weeks, spontaneous rupture of the membranes and preterm labor occurred, and quadruplet A, stillborn female weighing 260 g, was delivered. With the use of antibiotic therapy, tocolysis and bed rest, the remaining two fetuses were maintained in utero until 32 6/7 weeks' gestation, when quadruplet B, a 1,470-g female, and quadruplet C, a 1,700-g female, were delivered. CONCLUSION: This was the first reported case of surviving fetuses coexisting with a partial molar pregnancy. This case was also complicated by preterm delivery and successful delayed-interval birth in a quadruplet pregnancy.     

Delayed delivery. Two cases, and review of the literature

Delayed deliveries are rarely encountered in multiple pregnancies. They are useful in case of premature fetus. We report two case of delayed delivery; the first one of 23 days in a twin pregnancy, and the second one of 4 days in a triplet pregnancy. In both cases, the first delivered fetus died, and the later one or ones survived. Delayed delivery is a good management practice for multiple pregnancies in case of prematurity if no contraindications exist.     

Conservative treatment of multiple pregnancies after delivery and a fetal miscarriage: two case reports

Due to the increased availability of infertility treatment, multiple pregnancies, with various resulting complications, have become more common. Two cases of triplet pregnancies with delayed delivery--interval ranged from 6 to 56 days--are reported. The first woman in the 23rd week of a triplet pregnancy came to the hospital because of premature rupture of membranes of one amniotic sac and had a miscarriage of one of the fetuses the same day. The second woman in the 26th week of a triplet pregnancy also came to the hospital because of bleeding and contractions and had vaginal delivery of the first triplet a few hours later. After confirming that the remaining two fetuses were in good condition, both patients were kept under observation with only antibiotic therapy for the first one and antibiotic and tocolysis for the second. Fifty-six days following admission to our hospital the first woman gave birth to twins while in her 32nd week. The second woman gave birth six days following admission (in her 27th week). The successful outcome of these cases demonstrates that non-intervening conservative methods could be a feasible alternative to invasive intervention. We hope that our cases will encourage more physicians to try out and report non-intervening methods so that enough information can be gathered to help make correct management decisions in the future.     

Introduction to microscopic research of silver halides and related dispersed systems

> Objective: To establish whether uterine artery flow velocity waveforms in the second trimester are associated with adverse pregnancy outcome in women with a poor obstetric history. Methods: We reviewed the obstetric case notes of 50 women with a poor obstetric history in previous pregnancies in whom uterine artery flow velocity waveforms had been obtained at 18 weeks gestation. Results: In this population 40% had an adverse pregnancy outcome (preeclampsia, pregnancy-induced hypertension, preterm delivery, birthweight <10th percentile or perinatal death). Preeclampsia, perinatal death, and preterm delivery were all significantly associated with abnormal uterine artery waveforms at 18 weeks. Conclusions: Assessment of uterine artery flow velocity waveforms at 18 weeks gestation shows promise as a screening test in the high risk obstetric population. The technique requires formal evaluation in a prospective, double blinded study.     

Triplet pregnancy in premature ovarian failure after oocyte donation and in vitro fertilization: a case report and review of literature

Oocyte donation in premature ovarian failure patients has become an extended indication for In Vitro Fertilization (IVF) procedure. Here the first case report is presented in Taiwan, R.O.C. of a triplet pregnancy in a patient with premature ovarian failure. After an adequate hormonal replacement therapy with oral premarin and intramuscular progesterone for endometrium preparation, the transfer on D15 of four embryos (with donated oocytes and IVF) resulted in implantation of three. Pregnancy support was provided also by oral premarin and intramuscular progesterone until the tenth week of gestational age (GA). The patient received Caesarean section at 35 weeks GA with delivery of three healthy babies weighing 2530 gm, 2420 gm, and 1810 gm respectively on Aug. 17, 1990.     

Do stressful life events affect duration of gestation and risk of preterm delivery?

The present study was designed to test the relation between stressful life events experienced during pregnancy and the risk of preterm delivery and shortened duration of pregnancy. We collected data prospectively in a general population sample, including repeated questionnaire measures of exposure to stressful life events during pregnancy. Between August 1989 and September 1991, 8,719 Danish-speaking women with singleton pregnancies attended antenatal care. Of these women, 5,873 (67%) completed all questionnaires. When indicating an event, the woman was asked to rate the amount of stress induced by this event. Measurement of gestational duration was primarily based on early ultrasound scan. When we evaluated life events independently of the individual's appraisal, we found no association with duration of gestation or risk of preterm delivery. In contrast, life events assessed by the subject as highly stressful were associated with shorter mean duration of gestation and increased risk of preterm delivery. This association was observed primarily with events experienced between the 16th and 30th week of gestation. Women who had one or more highly stressful life events had a risk of preterm delivery 1.76 times greater than those without stressful events (95% confidence interval = 1.15-2.71). We found no evidence for a buffering effect of social support.     

Transvaginal ultrasonographic cervical assessment for the prediction of preterm delivery

To determine the usefulness of transvaginal ultrasonographic cervical assessment for the prediction of preterm delivery in an apparently normal population, 729 pregnant women (between 15 and 34 weeks' gestation) were randomly enrolled in the study in ten tertiary perinatal centers in Japan. Cervical parameters, including cervical length, internal os dilatation, and funneling depth, were measured by transvaginal ultrasound. The predictive values of these measurements for preterm delivery were investigated in a prospective fashion. Among various cervical parameters, cervical length showed the best correlation with pregnancy outcome. Cervical length (mm) was gradually decreased as the gestational age progressed, the regression line being y = 41.21-0.22x. When the mean cervical length minus 1 standard deviation at each gestational age was chosen as a cut-off value, the group with a shortened cervix showed a significantly high preterm delivery rate exclusively in the primigravidae (odds ratio: 4.86, 95% CI: 1.85-12.72). Internal os dilatation, in contrast, was a useful predictor in multiparous women (odds ratio: 6.00, 95% CI: 1.65-21.71). It was concluded that tranvaginal ultrasonographic cervical assessment, especially the measurement of cervical length, was effective for the prediction of preterm delivery in the primigravidae.     

Single live-birth after twin conception]

The authors discuss the pregnancy outcome following the demise of one or more embryos or fetuses of the set of a multiple pregnancy. The consequences depend, to great extent, upon the time of the intrauterine demise. Sonographic examination identifies the empty chorionic sacs when death of embryos occurred during the first trimester. Circulatory disturbance at the time of early embryogenesis led to the formation of a fetus acardius amorphus. One fetus died during the second trimester and careful sonographic search revealed laterally displaced fetus papyraceous. An other growth retarded, dead, small fetus was found closely attachd to the uterine wall (stuck twin). All these complications caused spontaneous fetal reduction in multiple gestations.     

Ultrasonographic and Biochemical Markers of Preterm Labor

> At present preterm delivery is the leading cause of perinatal morbidity and mortality and its incidence is remained stable during the past 10 years. Conventional methods of identifying patients at risk of preterm delivery such as obstetrics history, demographic factors or evaluation of uterine contractions and cervix by digital examination show disappointintly low sensitivity and positive predictive value. In this review we describe new ultrasonographic and biochemical approaches that have been recently proposed to screen for preterm labor both in patients with intact and with premature rupture of the membranes. The ultrasonographic detection of a short uterine cervix and/or of a dilation of the internal os, expression of weakening of the lower uterine segment or cervical ripening, seems to efficiently predict patients at risk of preterm delivery. The efficiency of this marker may be improved by the association with the assay of fetal fibronectin or pro inflammatory cytokines (interleukin-6 and interleukin-8) in cervical secretions. Further by the concentrations of interleukin-6 and interleukin-8 in cervical secretions seems to be possible to predict among patients in preterm labor those secondary to subclinical endoamniotic infection or chorioamnionitis. The use of these new markers in the future may allow a better identification of patients at risk of preterm labor and a proper selection of the treatment (medical or surgical) required for such patients.     

Fetal fibronectin in cervico-vaginal secretions--an indicator of incipient premature labor using a membrane immunoassay

The objective of the investigation was to test the presence of foetal fibronectin in the cervicovaginal secretion in symptomatic pregnancies and assess the possible prediction of imminent premature delivery. Prospectively 84 pregnant women were examined who were admitted to hospital with symptoms of imminent premature delivery between the 24th and 34th week of pregnancy (more than 20 contractions per day or a cervical score higher than the critical value for the given week of gestation). The secretion was collected by means of a dacron brush from the posterior labium of the portio vaginalis uteri and examined by a single-use kit FFN (Fetal Fibronectin Membrane Immunoassay, Adeza Co.). From the total of 84 specimens of secretions examined for the presence of foetal fibronectin 32 were positive and 52 negative. Of 32 pregnant women with a positive test 19 women delivered within two weeks, 13 were discharged and the deliveries took place after the 36th week of pregnancy. In the group of 52 women with a negative result of the test 50 women were discharged and the deliveries occurred after the 36th week of gestation; only two women who remained in hospital had premature deliveries within two weeks after collection of the specimen. In no patient discharged from hospital delivery occurred before the end of the 36th week of gestation. The finding of positive foetal fibronectin can be interpreted only as an increased risk of premature delivery (positive predictive value 59.4%). A negative test has a better predictive value. If the test is negative, there is a 96.1% probability that premature delivery will not occur (negative predictive value).     

Bilateral renal artery stenosis diagnosed during pregnancy

Bilateral renal artery stenosis was diagnosed noninvasively in the 17th gestational week, in a chronically hypertensive pregnant woman, by renal artery duplex ultrasound examination, MRI and MR angiography. Continuous monitoring of the mother and the fetus was performed. Blood pressure was stabilized by complex antihypertensive therapy, but from the beginning of the third trimester superimposed preeclampsia developed gradually. In the 34th gestational week a 1600-g newborn was delivered by elective cesarean section. The case report draws attention to the significance of the thorough examination of hypertensive women before pregnancy.     

In utero fetal death in multiple pregnancies during the second and third trimesters. A series of 21 cases

OBJECTIVE: Recall the maternal and fetal risks in multiple pregnancies with in utero death during the second and third trimester. METHODS: From january 1, 1984 through December 31, 1994 21 cases of in utero death occurred among 405 multiple pregnancies followed in our unit. The frequency and circumstances of maternal and fetal complications were established according to type of placenta implantation, etiology, term at death of the twin and delay from death to delivery. RESULTS: The rate of in utero death was 5.2%. Various etiologies were observed, but the main cause was intra-uterine growth retardation. Maternal complications were marked by moderate asymptomatic disorders in hemostasis which resolved rapidly. Fetal complications included premature delivery (20/25 infants) and multicystic encephalopathy in one surviving twin. In monochorial pregnancies there is either tromboplastin release or hypotension-hypoxia phenomena which lead to neurological lesions. CONCLUSION: Fetal prognosis depends essentially on the type of placenta implantation. The most severe fetal complications are caused by neurological damage occurring in monochorial pregnancies. Screening for this anomaly is difficult, limiting the antenatal evaluation to the prognosis of the surviving twin. In bichorial pregnancies, and even more so in monochorial pregnancies. It is important to prevent premature delivery and maintain regular obstetrical care. The ultrasound-Doppler examination is the key to follow-up in pregnancy.     

Acoustic neurinoma and facial nerve]

OBJECTIVES: To present the complications of twin pregnancies with delayed delivery of the second twin, 32 days after expulsion of the first twin. CASE: A 29-year-old woman with a twin pregnancy at gestational age 13 weeks and 5 days presenting with a rupture of the membranes of the first twin. At 21 completed weeks the umbilical cord prolapsed and at 23 weeks the first twin was stillborn with the placenta in the uterus. After maternal septicemia the second twin was delivered by caesarian section, at 28 complete weeks, liveborn. The mother and child were discharged from hospital 10 weeks later, corresponding to 38 completed weeks of pregnancy. CONCLUSIONS: A very early premature rupture of membrane (PROM) occurs more often in twin pregnancies. The delivery of one twin most often results in expulsion of the second twin. With PROM there is a great risk of chorioamnionitis, as in our case, which resulted in an acute cesarean section. In this case, conservative management achieved a viable fetus in spite of very early and serious complications.     

A comparison of sonographic growth curves of triplet and twin fetuses

Sonographic growth curves of 47 normal triplet pregnancies were compared with those of 71 uncomplicated twin gestations. Starting from the 25th week, the biparietal diameter in triplets was found to lag progressively compared with that of twins, reaching a mean difference of 2 weeks at 36 weeks gestation. Similarly, a significant difference was found between the femur length and head to abdomen circumference ratio growth curves of triplets and twins. It is concluded that as pregnancy continues from the 25th to the 36th gestational week, there is a significant delay in the growth patterns of normal triplet pregnancies compared with twin gestations.     

Animal Welfare Service of Lower Saxony--first report of experiences

A review was made of the medical records of 26 patients with uterine myomas during pregnancy between 1983 and 1992 among 12,965 deliveries. Thirteen patients underwent myomectomies before pregnancy. In three patients myomectomy was performed during pregnancy between the 12th and the 19th week of pregnancy. In ten patients myomectomy was performed during cesarean section delivery to prevent necrobiosis. Myomectomy should remain exceptional during pregnancy and it must be performed only in selected cases but is frequently used towards the end of a cesarean section. Indications for hysterectomy, on the other hand, remain limited.     

Triplet pregnancy with acardius acranius after preimplantation diagnosis

OBJECTIVE: To report the first case of fetal malformation after preimplantation diagnosis for Duchenne muscular dystrophy (DMD). DESIGN: Case report. SETTING: Perinatal center in a university hospital. PATIENT(S): A conductor for DMD in her third pregnancy. INTERVENTION(S): Preimplantation diagnosis was performed in an outside hospital. In our center, a dichorionic triplet pregnancy with acardius acranius was diagnosed. The anastomosis between the "pump"-twin and the fetus with acardius was embolized with histoacryl to prevent worsening cardiac insufficiency of the "pump"-twin. MAIN OUTCOME MEASURE(S): Pregnancy outcome. RESULT(S): The anastomosis between the "pump"-twin and the fetus with acardius was occluded successfully. Premature preterm rupture of membranes led to rapid labor and delivery at 24 + 5 weeks' gestation. The smaller girl died of severe hyaline membrane disease, whereas the other infant had no major clinical problems and has developed well. CONCLUSION(S): There might be an association between embryo biopsy and fetal malformations. The setting up of a birth register after embryo biopsy is strongly recommended.