Taiwanese Journal of Obstetrics and Gynecology

Pathophysiology of Increased Fetal Nuchal Translucency Thickness

Chih-Ping Chen — 2010-06-01

Summary: Increased fetal nuchal translucency thickness is associated with trisomy 13, trisomy 18, trisomy 21, Turner syndrome, other sex chromosome abnormalities, as well as many fetal anomalies and genetic syndromes. This article provides a comprehensive review of the cardinal proposed pathophysiology including altered composition of the extracellular matrix, abnormalities of the heart and great arteries, and disturbed or delayed lymphatic development.

Expression of a Hoechst 33342 Efflux Phenomenon and Common Characteristics Of Pluripotent Stem Cells in a Side Population of Amniotic Fluid Cells

Yieh-Loong Tsai, Yu-Jen Chang, Ching-Yu Chou, Mei-Leng Cheong, Ming-Song Tsai — 2010-06-01

Summary: Objective: The aim of this study was to verify the existence of a side population (SP) of cells in second-trimester amniotic fluid. Materials and Methods: Amniotic fluid samples (n = 35) were obtained, and the number and size of viable amniotic fluid cells (AFCs) were analyzed. Small AFCs (SAFCs) and large AFCs (LAFCs) were isolated using a sterile 10-μm pore size strainer. Hoechst 33342 dye exclusion assay, flow cytometry analysis, reverse transcriptase polymerase chain reaction and immunocytochemistry were used to analyze the characteristics of SAFCs and LAFCs. Results: The mean concentration of viable AFCs from 16 to 21 weeks of gestation was 0.3 × 105, 0.8 × 105, 1.1 × 105, 1.3 × 105, 1.0 × 105 and 1.0 × 105 cells/mL respectively. The mean percentage of SAFCs from 16 to 21 weeks of gestation was 27.3%, 40.5%, 49.7%, 60.2%, 41.0% and 58.2%, respectively. The Hoechst 33342 efflux phenomenon was obvious among SAFCs but was rare in the LAFC population. Flow cytometry analyses showed that cell surface antigen expression on LAFCs and SAFCs were positive for CD29, CD44, CD73, CD90, CD166 and HLA-I, but negative for CD31, CD34, CD45, CD117 and HLA-II. Importantly, Nanog, Oct-4, ABCG2 and SOX2 expression in cells was easily detectable among the SAFC population. Expression of Nanog and ABCG2 was not observed among LAFCs. Conclusion: Amniotic fluid contains a SP that was found mostly among the SAFCs. Enriched SP cells isolated by the efflux of Hoechst 33342 could be a novel and promising source of pluripotent-like amniotic derived stem cells for cellular therapy in the near future.

Abnormal Ductus Venosus Flow and Tricuspid Regurgitation at 11–14 Weeks' Gestation have High Positive Predictive Values for Increased Risk in First-Trimester Combined Screening Test: Results of a Pilot Study

Okan Ozkaya, Mekin Sezik, Demir Ozbasar, Hakan Kaya — 2010-06-01

Summary: Objective: To investigate the relationship between two novel first-trimester ultrasound markers (abnormal fetal ductus venosus [DV] flow and presence of tricuspid regurgitation [TR]) and the results of the first-trimester combined screening test in pregnancies with a normal karyotype. The screening test involves nuchal translucency measurement by ultrasound, and measurement of serum free β-chorionic gonadotropin and pregnancyassociated plasma protein A. Materials and Methods: The study included 58 pregnancies with amniocentesis-proven normal karyotypes and ultrasound-proven normal fetal anatomy. DV flow and TR were initially evaluated by ultrasound at 11–14 weeks' gestation. Sensitivity, specificity, and positive and negative predictive values of abnormal DV flow and TR for determining increased test risk (> 1 in 300) were calculated. Results: Abnormal DV flow and TR were detected in seven (12%) and six (10%) women, respectively. The sensitivities of abnormal DV flow, TR, and dual abnormalities (abnormal DV flow plus TR) for predicting increased risk in the combined screening test were low (33.3%, 27.7%, and 26.3%, respectively). However, their corresponding specificities (97.5%, 97.5%, and 100%) and positive predictive values (85.7%, 83.3%, and 100%) were reasonably high, with particularly low false-positive rates (2.5%, 2.5%, and 0%). When abnormal DV flow and TR were both positive, the combined test risk was consistently above 1 in 300. Conclusion: Determination of DV flow and TR as initial markers in unselected pregnancies merits further investigation, as the combination of these parameters might reliably predict an increased risk in combined screening test result, with low false positivity.

Induction of Labor: A Comparative Study of Intravaginal Misoprostol and Dinoprostone

2010-06-01

Summary: Objective: To compare the efficacy and safety of intravaginal misoprostol and dinoprostone for elective induction of labor in nulliparous women with an unfavorable cervix. Materials and Methods: A quasi-experimental study was conducted in Bahawal Victoria Hospital, Bahawalpur, Pakistan, from July 1, 2005 to August 31, 2006. A total of 120 primigravid women with gestational ages of > 40 weeks to < 42 weeks were divided into two groups. Group A (n = 60) was given 50 μg of misoprostol and Group B (n = 60) was given 3 mg of dinoprostone every 6 hours, for a maximum of three doses. Results: The induction to onset of significant uterine contractions and delivery intervals were lower in Group A than in Group B (6.1 vs. 7.2 hours; p = 0.16; and 8.2 vs. 11.0 hours; p = 0.007, respectively). Group A had a lower cesarean section rate than Group B (7% vs. 30%; p = 0.003), but a higher rate of uterine hyperstimulation (10% vs. 3%; p = 0.16), tachysystole (17% vs. 3%; p = 0.02), and neonatal admissions to the intensive care unit within 24 hours of delivery (4 vs. 3; p = 0.71) and after 24 hours (2 vs. 1; p = 0.56) than Group B. Conclusion: Vaginal misoprostol is more effective than dinoprostone for the elective induction of labor beyond 40 weeks of gestation, but is associated with more uterine hyperstimulation, tachysystole, and neonatal intensive care unit admissions.

Acute Fatty Liver of Pregnancy in a Taiwanese Tertiary Care Center: A Retrospective Review

2010-06-01

Summary: Objective: To evaluate the demographics, clinical presentations, laboratory findings, and maternal and fetal outcomes in patients with acute fatty liver of pregnancy. Materials and Methods: A retrospective review was conducted of the records of pregnant patients with a diagnosis of acute fatty liver in a tertiary medical center over a 22-year period. Results: Eighteen patients with acute fatty liver of pregnancy were recruited, all of whom developed the disease in the third trimester. Eleven women (61%) were primigravid and four (22%) had twin pregnancies; six (33%) were diagnosed antepartum, and the other 12 (67%) were diagnosed postpartum. There were two maternal deaths (11%) and four fetal deaths (18%). The most common complications apart from severe liver dysfunction were acute renal failure (83%), hypoglycemia (61%), and disseminated intravascular coagulation (61%). Conclusion: Women who become acutely ill during the third trimester of pregnancy should undergo tests for acute fatty liver of pregnancy, including laboratory tests for assessing liver function and coagulation profile.

Insertion of the Mirena Intrauterine System for Treatment of Adenomyosis-Associated Menorrhagia: A Novel Method

2010-06-01

Summary: Objective: Insertion of the levonorgestrel-releasing intrauterine system Mirena is difficult in women with adenomyosis, and the device is often subsequently expelled. We used a novel insertion technique (Yang's method) to overcome this problem. Materials and Methods: This retrospective study enrolled 273 patients with adenomyosis who were receiving Mirena for treatment of menorrhagia and/or dysmenorrhea between 2001 and 2008. Clinical outcomes and expulsion rates were compared between patients treated using conventional insertion and those treated using Yang's insertion methods. Results: Expulsion occurred in 25.3% of patients with the conventional method, compared with 10.2% of patients with Yang's method. Hemoglobin levels and dysmenorrhea improved greatly in both groups after Mirena insertion. Conclusion: Yang's insertion method for levonorgestrel-releasing intrauterine system is more reliable in some difficult cases, such as patients with severe adenomyosis. This method ensures correct positioning, thus reducing the risks of uterine perforation and/or expulsion.

Analysis of Cases of Sexual Assault Presenting at A Medical Center in Taipei

2010-06-01

Summary: Objective: Sexual assault is a form of interpersonal violence with significant consequential health problems. The purpose of this study was to describe the characteristics of the victims, assaults, and associated physical and psychologic trauma of sexual assault cases in Taipei. Materials and Methods: Data were retrospectively collected from the medical records of sexual assault victims who visited the emergency department of a medical center in Taipei from 1991 to 2003. The characteristics of the victims, assaults, and factors associated with general body and genital trauma were analyzed. Results: There were 114 sexual assault victims, including 107 females and seven males, aged from 3 to 49 years (mean, 17.9 years). Overall, 72.3% of victims had evidence of physical trauma. Genital/anal injuries (53.3%) occurred more often than general body trauma (41.0%). The presence of general body injuries was positively associated with physical examination within 72 hours, and negatively associated with a victim age younger than 18 years. Genital/anal lesions were significantly more common in victims without prior sexual intercourse. Conclusion: The results of physical examination in sexual assault victims were related to early examination, age, and sexual experience.

Incidence of and Risk Factors for Birth Trauma in Iran

2010-06-01

Summary: Objective: Birth trauma at delivery is a rare but significant prenatal complication. The aim of this study was to determine the incidence of birth trauma and risk factors related to fetal injury. Materials and Methods: Birth trauma was evaluated in singleton fetuses with no major anomalies and with vertex presentations over a 3-year period from 2002 to 2005. One hundred and forty-eight neonates, who experienced birth trauma, were prospectively identified and compared with 280 normal neonates. Both groups were delivered vaginally. Maternal and infant characteristics were evaluated as possible risk factors for fetal injury. Results: Among the 148 infants with birth trauma, nine had multiple injuries. The most common injury was cephalohematoma (n = 77). Other injuries included clavicle fractures (n = 56), brachial plexus paralysis (n = 13), asphyxia (n = 7), facial lacerations (n = 4), brain hemorrhage (n = 1), and skin hematoma (n = 2). Multiple regression analysis identified premature rupture of membranes, instrumental delivery, birth weight, gestational age, induction of labor, and academic degree of attendant physician at delivery as the most significant risk factors for birth trauma. Conclusion: The incidence of birth trauma was 41.16 per 1,000 vaginal deliveries. Induction of labor, premature rupture of membranes, academic degree of attendant physician at delivery, higher birth weight, and gestational age were associated with fetal injuries.

Epicatechin Gallate Decreases the Viability and Subsequent Embryonic Development of Mouse Blastocysts

Hsiao-Chen Tu, Chih-Ping Chen, Wen-Hsiung Chan — 2010-06-01

Summary: Objective: Catechins, a family of polyphenols found in tea, evoke various responses including cell death. We examined the cytotoxic effects of epicatechin gallate (ECG), a polyphenol extract from green tea, on the blastocyst stage of mouse embryos, subsequent embryonic attachment, and in vitro and in vivo outgrowth implantation after embryo transfer. Materials and Methods: Mouse blastocysts were incubated in medium with or without ECG (12.5μM, 25μM or 50μM) for 24 hours. Cell proliferation and growth were investigated using dual differential staining, apoptosis was analyzed with terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling, and implantation and post-implantation development of embryos were measured by in vitro development analysis and in vivo embryo transfer, respectively. Results: Blastocysts treated with 50μM ECG exhibited a significant increase in apoptosis and a corresponding decrease in total cell number. Importantly, the implantation success rate of blastocysts pretreated with 50μM ECG was lower than that of controls, and in vitro treatment with 50μM ECG was associated with increased resorption of post-implantation embryos and decreased fetal weight. Conclusion: Our results collectively indicate that in vitro exposure to ECG induces apoptosis and retards early post-implantation development after transfer to host mice. The degree of teratogenic potential exerted by ECG in early human development is unknown at present and requires further investigation.

Selenium Supplementation and the Incidence of Preeclampsia in Pregnant Iranian Women: A Randomized, Double-Blind, Placebo-Controlled Pilot Trial

2010-06-01

Summary: Objective: Recent studies have reported that antioxidant status, including serum selenium concentrations, is altered in women who develop preeclampsia. We wished to examine the effects of selenium supplementation in the prevention of preeclampsia in high-risk pregnant women. Design: We carried out a randomized, double-blind, placebo-controlled pilot trial. A total of 166 primigravid pregnant women, who were in the first trimester of pregnancy, were randomized to receive 100 μg of selenium (n = 83; dropouts, n = 22) or a placebo (n = 83; dropouts, n = 19) per day until delivery. The incidence of preeclampsia, serum selenium concentrations, lipid profile and high-sensitivity C-reactive protein status were evaluated at baseline and at the end of the study. Results: Supplementation with selenium was not associated with any reported major side effects and was associated with a significant increase in mean serum selenium concentrations at term (p < 0.001). In contrast, mean serum selenium concentrations remained unchanged in the control group (p = 0.63). The incidence of preeclampsia was lower in the selenium group (n = 0) than in the control group (n = 3), although this was not statistically significant (p > 0.05). After treatment, systolic and diastolic blood pressure, serum total cholesterol, triglycerides, low-density and high-density lipoprotein cholesterol, and high-sensitivity C-reactive protein were significantly increased in both groups compared with pretreatment levels (p < 0.05). Conclusion: Our findings indicate that selenium supplementation in pregnant women may be associated with a lower frequency of preeclampsia.

Prenatal Diagnosis and Molecular Cytogenetic Characterization of a Small Supernumerary Marker Chromosome Derived from Chromosome 18 and Associated With a Reciprocal Translocation Involving Chromosomes 17 And 18

2010-06-01

Summary: Objective: Prenatal diagnosis of small supernumerary marker chromosomes (sSMC) gives rise to difficulties in genetic counseling, and requires molecular cytogenetic technologies such as spectral karyotyping, fluorescence in situ hybridization, multicolor-fluorescence in situ hybridization, or array-comparative genomic hybridization to identify the nature of the aberrant chromosome. We report such a case associated with a reciprocal translocation. Materials, Methods and Results: A 36-year-old woman, gravida 7, para 1, abortus 5, was referred for amniocentesis at 18 weeks of gestation because of advanced maternal age. Amniocentesis revealed a reciprocal translocation between chromosomes 17q and 18q and an sSMC. The karyotype was 47,XY,t(17;18)(q11.1;q11.2), +mar. Chromosome preparations from blood lymphocytes revealed that she had the same reciprocal translocation and sSMC. Spectral karyotyping showed that the sSMC was derived from the centromeric region of chromosome 18, and there was a reciprocal translocation between chromosomes 17 and 18. The derivative chromosome 17 had positive 17p terminal (17pTEL) and chromosome 17 centromeric (cep17) signals but did not have a positive chromosome 18 centromeric signal (cep18). The derivative chromosome 18 had positive 18p terminal (18pTEL), chromosome 18 centromeric (cep18) and cep17 signals. The sSMC had only a positive cep18 signal. These findings suggested that a breakpoint occurred at 17q11.1 and another at 18q11.2 during translocation, and the sSMC originated from chromosome 18. The karyotype of the fetus was thus 47,XY,t(17;18)(q11.1;q11.2), +mar.ish der(17)t(17;18)(q11.1;q11.2)(17pTEL+,D17Z1+),der(18)t(17;18)(q11.1;q11.2)(18pTEL+,D18Z1+,D17Z1+), + der(18)(D18Z1+). Oligonucleotide-based array comparative genomic hybridization demonstrated no gain or loss of the gene dosage on chromosomes 17 and 18. Conclusion: Our case adds to the reported cases of sSMCs derived from the centromeric region of chromosome 18 without phenotypic consequences.

Mastocytosis in Pregnancy

2010-06-01

Summary: Objective: Mastocytosis is a rare disorder characterized by abnormal accumulation of mast cells in various organs. Clinical complaints include pruritus, cutaneous flushing, dyspepsia, and episodes of anaphylaxis, and are usually the result of local and systemic mast cell mediator release. The triggers include a variety of factors including drugs, exercise, stress, anxiety, and temperature extremes. Case Report: A 26-year-old primigravida at 40 weeks' gestation with urticaria pigmentosa presented to our hospital. She was diagnosed with cutaneous mastocytosis based on pathologic examination of her skin biopsy. There were no complications during pregnancy, except for cutaneous manifestations with pruritus and premature uterine contractions at 27 weeks' gestation. After admission, antihistamine agents were administered during labor to treat the above symptoms, and antibiotic agents were given for prophylaxis of chorioamnionitis. Labor pain was successfully managed with warm showers, frequent position changes and massage, and therefore, epidural analgesia was not carried out. After 6 hours of labor, the patient gave birth to a healthy female infant via normal spontaneous vaginal delivery with right mediolateral episiotomy. Neither local anesthetic agents nor antibiotic agents caused any reaction. The postpartum period was uneventful. Conclusion: Pregnant women with mastocytosis should be treated symptomatically and should avoid factors that may exacerbate symptoms of disease. Clinicians should be aware of preterm labor during pregnancy. As a preventive measure, resuscitation equipment should be available during the labor, delivery and postpartum period to treat unanticipated hypotension and shock.

Placenta Accreta Following Uterine Artery Embolization

Hironori Takahashi, Satoshi Hayashi, Kentaro Matsuoka, Michihiro Kitagawa — 2010-06-01

Summary: Objective: Uterine artery embolization (UAE) is becoming a common treatment for symptomatic leiomyoma. Several pregnancies following UAE have been reported. However, reports are still limited and the risk of complications remains unknown. Case Report: A primigravida conceived after UAE for leiomyoma. She delivered spontaneously at 34 weeks plus 2 days after premature rupture of the membranes. The placenta was located on the interstitial leiomyoma. The patient required manual placental extraction owing to retained placenta and subsequently underwent emergency supracervical hysterectomy for severe postpartum hemorrhage. Placenta accreta was confirmed histologically. Conclusion: Placenta accreta may occur during pregnancy following UAE. When the implantation site is on the leiomyoma with a hyperechoic rim, there is a high risk of abnormal placental adherence.

Assisted Reproductive Treatment Applications in Men With Normal Phenotype But 45,X/46,Xy Mosaic Karyotype: Clinical and Genetic Perspectives

2010-06-01

Summary: Objective: The 45,X/46,XY mosaic karyotype is expressed by a spectrum of genital phenotypes, ranging from normal males through to ambiguous genitalia and to normal females. Case Reports: We present three cases of men with azoospermia or severe oligozoospermia, and a 45,X/46,XY mosaic karyotype and two with a Y-chromosome microdeletion. Phenotypically, they appeared as normal males, with normal penis, scrotum and secondary sex characteristics. Testicular sperm extraction and aspiration were applied to patients, and couples were prepared for assisted reproductive therapy. All men with azoospermia or severe oligozoospermia were evaluated for karyotype and Y-chromosome microdeletion even if they had normal phenotypes. Conclusion: Possibilities for finding sperm and the biologic paternity in subjects with 45,X/46,XY karyotype should be considered. Furthermore, the increased risk for testicular neoplasia with mosaic karyotypes should be taken into consideration.

Highly Cellular Leiomyoma Mimics A Malignant Small Round-Cell Tumor: A Diagnostic Dilemma On Frozen Sections

Somak Roy, Vijay Saroha, Deepali Jain — 2010-06-01

Summary: Objective: Cellular leiomyoma is characterized by significantly increased cellularity and may mimic malignant tumors. Our aim was to differentiate these from other malignant small round-cell tumors. Case Report: We report a case of cellular leiomyoma that mimicked a malignant small round-cell tumor upon frozen section examination. Conclusion: Pathologists should be aware that highly cellular leiomyomas can mimic malignant tumors especially on frozen section analysis.

Detection and Comparison of Cytomegalovirus DNA Levels in Amniotic Fluid and Fetal Ascites in a Second-Trimester Fetus With Massive Ascites, Hyperechogenic Bowel, Ventriculomegaly and Intrauterine Growth Restriction

2010-06-01

Summary: Objective: To present a prenatal diagnosis of congenital cytomegalovirus (CMV) infection in a pregnancy with fetal ascites. Case Report: A 33-year-old, gravida 6, para 2, woman was referred to a hospital at 20 weeks of gestation for management of fetal ascites. The woman had not experienced recent rubella or herpes simplex infections. The maternal blood group was O and Rh(D)-positive. The maternal serum thalassemia and syphilis screen results were negative. Fetal ascites was first noted at 17 weeks of gestation. At 18 weeks, she underwent amniocentesis revealing a 46,XX karyotype. At 20 weeks of gestation, maternal serum CMV IgG and CMV IgM were positive. At 21 gestational weeks, prenatal ultrasound showed fetal ascites, hyperechogenic bowel, ventriculomegaly, and intrauterine growth restriction. Repeated amniocentesis showed CMV DNA levels of 9.72 × 105 copies/mL and 6.03 × 105 copies/mL in amniocytes and amniotic fluid supernatant, respectively. Paracentesis showed CMV DNA levels of 1.64 × 103 copies/mL and 114 copies/mL in ascitic cells and ascitic supernatant, respectively. The pregnancy was terminated. Postnatally, CMV DNA was detected in the umbilical cord, amnion, placenta, cord blood, lungs, liver and brain by quantitative real-time polymerase chain reaction. Conclusion: A prenatal diagnosis of fetal ascites in association with ventriculomegaly, hyperechogenic bowel and intrauterine growth restriction should alert physicians to congenital CMV infection in addition to aneuploidy. The present case provides evidence that CMV DNA levels are higher in amniotic fluid (amniocytes and amniotic fluid supernatant) than in ascites (ascitic cells and ascitic supernatant) in cases of congenital CMV infection.

Fertility Preserving Surgical Management of Methotrexate-Resistant Cesarean Scar Pregnancy

Cem Ficicioglu, Rukset Attar, Gazi Yildirim, Nilufer Cetinkaya — 2010-06-01

Spontaneously Ruptured Subcapsular Liver Hematoma Associated With Hemolysis, Elevated Liver Enzymes and Low Platelets (HELLP) Syndrome

Pei-Yi Chou, Chen-Hsiang Yu, Chien-Chin Chen, Wen-Tsung Chen — 2010-06-01

Parasitic Leiomyosarcoma After Myomectomy

Kuan Chiao Lee, Ming-Shyen Yen, Peng-Hui Wang — 2010-06-01

A Huge Leiomyoma Subjected to a Myomectomy During a Cesarean Section

2010-06-01

Bell Palsy and Preeclampsia Superimposed on Chronic Hypertension

2010-06-01

Gossypiboma Mimicking an Ovarian Tumor in a Young Woman With a History of Ovarian Teratoma

2010-06-01

Vertebral Tumors Mimicking Exaggerated Pregnancy Symptoms—A Need for Careful Evaluation

Gulshan Saeed, Shazia Fakhar, Innayatullah Khan — 2010-06-01

Apert Syndrome Associated With Upper Airway Obstruction and Gastroesophageal Reflux Inducing Polyhydramnios in the Third Trimester

2010-06-01

Mosaic Tetrasomy 12P With Discrepancy Between Fetal Tissues and Extraembryonic Tissues: Molecular Analysis and Possible Mechanism of Formation

2010-06-01

Detection of Balanced Homologous Acrocentric Rearrangement REA(14Q14Q) and Low-Grade X-Chromosome Mosaicism in a Couple With Repeated Pregnancy Losses

2010-06-01

Fetal Magnetic Resonance Imaging Demonstration Of Central Nervous System Abnormalities and Polydactyly Associated With Joubert Syndrome

2010-06-01