1/7. The Zavanelli manoeuvre in shoulder dystocia: case report and review of published cases. A case of severe shoulder dystocia is reported in which, after other methods had failed, cephalic replacement succeeded but was very difficult. The infant suffered severe damage. A review of methods to relieve shoulder dystocia is given, with special attention to published cases of the Zavanelli manoeuvre. It could only be used when all other methods fail. ( info) |
2/7. Expectant management of severe preterm preeclampsia: is intrauterine growth restriction an indication for immediate delivery? OBJECTIVE: Expectant management of severe preterm preeclampsia is gaining widespread acceptance in clinical practice. The objective of our study was 2-fold-to determine the frequency of fetal deterioration with expectant management of severe preterm preeclampsia and to evaluate whether the presence of intrauterine growth restriction on admission is associated with a shorter admission-to-delivery interval or more deliveries resulting from nonreassuring fetal status in comparison with pregnancies with preeclampsia but without intrauterine growth restriction. STUDY DESIGN: This was an observational study of women with singleton pregnancies at <34 completed weeks' gestation who were admitted to the hospital with the diagnosis of severe preeclampsia and managed expectantly. Fetal status on admission, admission-to-delivery interval, indication for delivery, and neonatal outcome were examined. RESULTS: Forty-seven women were studied during a 3-year period (1996-1999). gestational age at admission was 29.8 /- 2.6 weeks. The mean admission-to-delivery interval for the entire group was 6.0 /- 5.1 days; in 42.5% delivery was for fetal indications. In comparison with the absence of intrauterine growth restriction, the presence of intrauterine growth restriction at admission resulted in a significantly shorter admission-to-delivery interval (3.1 /- 2.1 vs 6.6 /- 6.1 days; P <.05). Most fetuses with intrauterine growth restriction (85.7%) were delivered before 1 week. Although 57% of fetuses with intrauterine growth restriction were delivered for fetal indications, versus 39% of fetuses without intrauterine growth restriction, these rates were not found to be significantly different. Neonatal outcomes, as reflected by Apgar scores, number of admissions to and duration of stay in the neonatal intensive care unit, and neonatal mortality rates, were similar. CONCLUSION: Pregnancies complicated by severe preterm preeclampsia and the presence of intrauterine growth restriction at admission may not benefit from expectant management beyond the 48 hours needed for betamethasone to act. Furthermore, all patients may benefit from close fetal monitoring before delivery because of the high rate of intervention for deteriorating fetal status. ( info) |
3/7. Late onset of discordant growth in a monochorionic twin pregnancy: vascular anastomoses determine fetal growth pattern and not placental sharing. Twin-twin transfusion syndrome in monochorionic twin pregnancies has a complex and variable clinical presentation. We present the first documented case where two unidirectional arteriovenous anastomoses connecting the donor twin's larger with the recipient's smaller placental part produce late onset of discordant growth and subsequent twin-twin transfusion syndrome. We conclude that the haemodynamic effects of the anastomoses caused the observed discordant fetal development and not the unequally shared placenta. ( info) |
4/7. Prenatal findings on ultrasound and X-ray in a case of overgrowth syndrome associated with increased nuchal translucency. A case of prenatal diagnosis of an overgrowth syndrome at 30 weeks of gestation is reported. The diagnosis was suggested on the basis of increased fetal growth from 16 weeks onwards, advanced bone age, and characteristic facial features such as hypertelorism, broad forehead and small chin. The fetus presented at 12 weeks with a markedly increased nuchal translucency thickness and generalized skin edema, but normal karyotype. Serial ultrasound scans revealed brain abnormalities including mild unilateral ventriculomegaly and a cyst in the cavum septi pellucidi. The pregnancy was terminated at the parents' request at 32 weeks of gestation and postmortem examination confirmed the prenatal findings. This case demonstrates the possibility of prenatal diagnosis of early overgrowth syndromes and highlights the dilemma arising from the prenatal diagnosis of a non-lethal condition associated with an uncertain prognosis and poorly documented in utero. ( info) |
| The alagille syndrome (AGS) is a multisystem autosomal dominant condition. In this case report, we describe a pregnant woman with this unusual disorder, in whom serial fetal sonography revealed severe pulmonary stenosis and progressively severe intrauterine growth retardation, suggesting that the fetus also had AGS, a diagnosis which was confirmed postnatally. In this report, the potential complications for pregnancy, labor and delivery when both mother and fetus are affected with AGS are described. ( info) |
6/7. Outcome of prenatally diagnosed trisomy 6 mosaicism. We report the prenatal diagnosis of trisomy 6 mosaicism via amniocentesis, in which trisomy 6 cells were identified in three of five culture vessels with 33% (5/15) of colonies showing trisomic cells. The pregnancy was electively terminated and examination revealed minor abnormalities (shortening of the femurs, micrognathia, posterior malrotation of the ears, and bilateral camptomelia of the second digit of the hands and fifth digits of the feet). cytogenetic analysis of the placenta showed trisomy 6 in 100% of 20 cells studied. karyotype was 46,XX in 100 cells examined from fetal skin. There are relatively few prenatally diagnosed cases of mosaic trisomy 6 at amniocentesis. Confined placental mosaicism (CPM) has been postulated in other cases where follow-up cytogenetic studies were not available. The present case differs from those previously reported, as it appears to represent CPM of chromosome 6 with phenotypic effects to the fetus. ( info) |
7/7. Cervical neck dislocation associated with the Zavanelli maneuver. BACKGROUND: In the management of shoulder dystocia, fetal head replacement into the uterus has been advocated should delivery attempts remain unsuccessful. Reports of the Zavanelli maneuver have been remarkably optimistic despite the challenges of the procedure. CASE: A gravida 3 para 2 (two previous vaginal deliveries of more than 4,500-g infants) with gestational diabetes presented at term. Following a low forceps delivery, shoulder dystocia was encountered and was unable to be relieved with standard maneuvers. A cesarean delivery was performed, shoulders disimpacted, and the infant delivered abdominally. A 4,680-g stillborn infant was delivered with radiologic and autopsy evidence of cervical C5-C6 dislocation. CONCLUSION: Despite published reports of high success rates and limited fetal consequences, physicians should be aware of adverse consequences including cervical neck trauma associated with use of the Zavanelli maneuver. ( info) |