Sonographic Findings of Medullary Thyroid Carcinoma Leading to Diagnosis of Multiple Endocrine Neoplasia Type 2a during Pregnancy

Multiple endocrine neoplasia (MEN) type 2a (Sipple's syndrome) is characterized by medullary thyroid carcinoma and pheochromocytoma, and in a smaller percentage of cases, multiglandular parathyroid hyperplasia. This autosomal-dominant syndrome is due to a mutation in the rearranged during transfection (RET) proto-oncogene located on chromosome 10cen–10q11.2 and rarely complicates pregnancy. We present an unusual case in a patient with an enlarged thyroid with sonographic findings characteristic of thyroid cancer, which led to diagnosis and subsequent management of RET proto-oncogene-positive MEN type 2a complicating pregnancy

Extensive fundal placenta accreta spectrum (PAS) in a nulliparous patient with an unscarred uterus and systemic lupus erythematosus (SLE) necessitating cesarean hysterectomy at delivery

Placenta accreta spectrum (PAS) defined by various degrees of abnormally invasive placentation is strongly associated with severe maternal morbidity and maternal mortality, mainly reflecting maternal hemorrhage. Predisposing factors for this condition include: multiparity, placenta previa, previous uterine surgeries (previous curettage, cesarean delivery, and myomectomy), smoking and previous PAS. Prenatal sonographic findings associated with PAS include the presence of placenta previa, loss of the hypoechoic retroplacental sonolucency, myometrial thinning, interruption of the irregularity of the bladder wall, excessive vascularity of the uterovesical plane, placental lacunae, increased placental vascularity, bridging vessels with vascularity extending from the placental bed across the uterine wall into the bladder or other pelvic organs. PAS is very rare among nulliparous patients, especially those without previous uterine surgery. We describe an unusual case of PAS in a nulliparous patient with an unscarred uterus and systemic lupus erythematosus in whom a fundal placenta with PAS and thinned and areas of absent myometrium suspected at midtrimester sonography, sustained uterine atony and severe hemorrhage at delivery, necessitated massive blood transfusion and subtotal hysterectomy. Both mother and infant did well. Pathology confirmed PAS and marked uterine thinning. Although PAS most commonly is associated with placenta previa and the presence of previous cesarean delivery, this case emphasizes the need for alertness of at times subtle prenatal sonographic findings of PAS irrespective of placental location even among nulliparous patients, especially those with systemic lupus erythematosus

Peripartum Primary Prophylaxis Inferior Vena Cava Filter Placement in a Patient with Stage IV B-Cell Lymphoma Presenting with a Pathologic Femur Fracture

Abstract Background Pulmonary embolus (PE) remains a leading etiology of maternal mortality in the developed world. Increasing utilization of retrievable inferior vena cava (IVC) filter placement currently includes pregnant patients. Case A 22-year-old woman at 27 weeks' gestation was diagnosed with Stage IV high-grade malignant B cell lymphoma following pathologic femur fracture. Significant risk factors for PE led to placement of primary prophylaxis IVC filter before cesarean delivery, open reduction and internal fixation of the fractured femur, and chemotherapy. Conclusion This case supports that primary prophylaxis placement of IVC filters in highly selected pregnant patients may assist in decreasing PE-associated maternal mortality

Sonographic findings of complete tubal abortion

Ectopic pregnancies, implantation of a fertilized ovum in any location other than within the endometrial cavity, occur in 1-2% of all pregnancies. Despite current enhanced early diagnosis enabled by serum beta-human choriogonadotropin (hCG) levels and high-resolution ultrasound, this clinical entity continues to account for between 2.7 and 6% of all maternal deaths. The most common site of ectopic implantation is the Fallopian tube (>90% of cases), and less commonly in previous Cesarean scar, ovary, cervix, or the abdomen. Complete tubal abortion refers to a tubal pregnancy having been expelled from the distal portion of the Fallopian tube into the peritoneal cavity and may be associated with either considerable hemorrhage, spontaneous resolution, or rarely serve as an initial nidus for an abdominal pregnancy. We present unusual sonographic findings of a complete tubal abortion in a patient with minimal symptomology

Prenatal sonographic findings of prominent fetal tricuspid annulus: A case report

The tricuspid valve positioned between the right atrium and right ventricle is composed of 3 leaflets (anterior, posterior, and septal) anchored by a collagenous fibrous annulus, a saddle-shaped, oval structure, providing a firm yet dynamic structural support for the tricuspid valve. The annulus is considered to separate between the right atrium and right ventricle. Structural anomalies of the fetal tricuspid valve are rare and include Ebstein's anomaly, tricuspid atresia, partial absence, unguarded tricuspid orifice (absent leaflets) cleft, double orifice, bicuspid valve and Uhl anomaly (absence of the right ventricular myocardium with an apposing endocardium and epicardium). We present an unusual case in which a prominent peripheral circular structure was noted above the periphery of the fetal tricuspid valve at 31 weeks’ gestation. Inflow across the tricuspid valve was unimpaired, with no tricuspid regurgitation. The right atrium appeared normal with a normal functioning foramen ovale, and the entire fetal cardiac anatomy and function were normal with no signs of congestive cardiac failure or fetal hydrops. The prominent non-obstructing circular structure in immediate proximity to the tricuspid valve leaflets was considered to represent a prominent tricuspid annulus. An appropriate for gestational age fetus was delivered at term and neonatal echocardiography was normal. This case emphasizes that normal variations in fetal anatomical structures should always be considered and specifically that unimpaired inflow across the tricuspid valve in diastole is key upon encountering an unusually prominent fetal tricuspid annulus, which may be noted at a considerable distance above the tricuspid leaflets within the right atrium

Reverse diastolic flow of the fetal middle cerebral artery associated with placental chorangiomatosis and asymptomatic concealed placental abruption

Reverse diastolic flow of the fetal middle cerebral artery is a rare, yet ominous finding which has been associated with adverse perinatal outcomes including: intracranial hemorrhage, growth restriction, fetal-maternal hemorrhage, severe anemia, hydrops, hepatic anomaly, subsequent stillbirth, and early neonatal death. We report a case in which following notation of a nonreassuring fetal heart rate at 32 weeks’ gestation, sonographic documentation of persistent reverse diastolic flow of the fetal middle cerebral artery was noted in association with sonographic findings of vascular placental dysmorphology and an asymptomatic concealed placental abruption. Subsequent fetal heart rate tracing consistent with uteroplacental insufficiency led to immediate Cesarean birth of an anemic yet nonacidotic, nonhypoxic neonate, who did well following management of respiratory distress syndrome and partial exchange transfusion. Placental abruption was confirmed at delivery. Histopathology of the placenta confirmed the presence of localized chorangiomatosis (“wandering” chorangioma). The association of reverse diastolic flow of the fetal middle cerebral artery, placental chorangiomatosis and placental abruption has not been reported previously. We conclude that in the presence of prenatal sonographic findings of placental dysmorphology and or placental abruption, insonation of the fetal middle cerebral artery should be performed to assess the possibility of increased peak systolic velocity and possible reverse diastolic flow, both associated with fetal anemia and increased likelihood of an adverse perinatal outcome

Sonographic findings of transient marked proximal bowel dilatation in a growth-restricted fetus at 35 weeks’ gestation

Etiologies underlying the relatively infrequent third-trimester sonographic depiction of dilated fetal bowel include (functional or mechanical) bowel obstruction, intestinal atresia, volvulus, annular pancreas, intestinal malrotation, intussusception, gastrointestinal duplications, cystic fibrosis-associated meconium ileus, congenital chloride diarrhea, microvillus inclusion disease, intestinal neuronal dysplasia, and meconium plug syndrome. Fetal bowel obstruction may be associated with aneuploidy (mostly Trisomy 21 in association with esophageal or duodenal atresia), and rarely select microduplications or deletions. We present unusual sonographic findings associated with transient marked proximal fetal bowel dilatation in association with concurrent development of oligohydramnios, in a growth-restricted fetus at 35 weeks’ gestation. This case supports that upon observation of dilated loops of fetal bowel, while not negating the potential need for delivery secondary to potential bowel compromise, consideration should be given for observation in anticipation of potential spontaneous resolution of this condition, especially among growth-restricted fetuses with decreased amniotic fluid volume in prematurity

Human Fetal Exposure to Triclosan and Triclocarban in an Urban Population from Brooklyn, New York

Triclosan (TCS) and triclocarban (TCC) are antimicrobial agents formulated in a wide variety of consumer products (including soaps, toothpaste, medical devices, plastics, and fabrics) that are regulated by the U.S. Food and Drug Administration (FDA) and U.S. Environmental Protection Agency. In late 2014, the FDA will consider regulating the use of both chemicals, which are under scrutiny regarding lack of effectiveness, potential for endocrine disruption, and potential contribution to bacterial resistance to antibiotics. Here, we report on body burdens of TCS and TCC resulting from real-world exposures during pregnancy. Using liquid chromatography tandem mass spectrometry, we determined the concentrations of TCS, TCC, and its human metabolites (2′-hydroxy-TCC and 3′-hydroxy-TCC) as well as the manufacturing byproduct (3′-chloro-TCC) as total concentrations (Σ−) after conjugate hydrolysis in maternal urine and cord blood plasma from a cohort of 181 expecting mother/infant pairs in an urban multiethnic population from Brooklyn, NY recruited in 2007–09. TCS was detected in 100% of urine and 51% of cord blood samples after conjugate hydrolysis. The interquartile range (IQR) of detected TCS concentrations in urine was highly similar to the IQR reported previously for the age-matched population of the National Health and Nutrition Examination Survey (NHANES) from 2003 to 2004, but typically higher than the IQR reported previously for the general population (detection frequency = 74.6%). Urinary levels of TCC are reported here for the first time from real-world exposures during pregnancy, showing a median concentration of 0.21 μg/L. Urinary concentrations of TCC correlated well with its phase-I metabolite ∑-2′-hydroxy-TCC (<i>r</i> = 0.49) and the manufacturing byproduct ∑-3′-chloro-TCC C (<i>r</i> = 0.79), and ∑-2′-hydroxy-TCC correlated strongly with ∑-3′-hydroxy-TCC (<i>r</i> = 0.99). This human biomonitoring study presents the first body burden data for TCC from exposures occurring during pregnancy and provides additional data on composite exposure to TCS (i.e., from both consumer-product use and environmental sources) in the maternal–fetal unit for an urban population in the United States

Associations between nutrients in one-carbon metabolism and fetal DNA methylation in pregnancies with or without gestational diabetes mellitus

Abstract Background Gestational diabetes mellitus (GDM), characterized by hyperglycemia that develops during pregnancy, increases the risk of fetal macrosomia, childhood obesity and cardiometabolic disorders later in life. This process has been attributed partly to DNA methylation modifications in growth and stress-related pathways. Nutrients involved with one-carbon metabolism (OCM), such as folate, choline, betaine, and vitamin B12, provide methyl groups for DNA methylation of these pathways. Therefore, this study aimed to determine whether maternal OCM nutrient intakes and levels modified fetal DNA methylation and in turn altered fetal growth patterns in pregnancies with and without GDM. Results In this prospective study at a single academic institution from September 2016 to June 2019, we recruited 76 pregnant women with and without GDM at 25–33 weeks gestational age and assessed their OCM nutrient intake by diet recalls and measured maternal blood OCM nutrient levels. We also collected placenta and cord blood samples at delivery to examine fetal tissue DNA methylation of the genes that modify fetal growth and stress response such as insulin-like growth factor 2 (IGF2) and corticotropin-releasing hormone (CRH). We analyzed the association between maternal OCM nutrients and fetal DNA methylation using a generalized linear mixed model. Our results demonstrated that maternal choline intake was positively correlated with cord blood CRH methylation levels in both GDM and non-GDM pregnancies (r = 0.13, p = 0.007). Further, the downstream stress hormone cortisol regulated by CRH was inversely associated with maternal choline intake (r = − 0.36, p = 0.021). Higher maternal betaine intake and serum folate levels were associated with lower cord blood and placental IGF2 DNA methylation (r = − 0.13, p = 0.049 and r = − 0.065, p = 0.034, respectively) in both GDM and non-GDM pregnancies. Further, there was an inverse association between maternal betaine intake and birthweight of infants (r = − 0.28, p = 0.015). Conclusions In conclusion, we observed a complex interrelationship between maternal OCM nutrients and fetal DNA methylation levels regardless of GDM status, which may, epigenetically, program molecular pathways related to fetal growth and stress response

Maternal Mercury Exposure, Season of Conception and Adverse Birth Outcomes in an Urban Immigrant Community in Brooklyn, New York, U.S.A.

Adverse birth outcomes including preterm birth (PTB: &lt;37 weeks gestation) and low birth weight (LBW: &lt;2500 g) can result in severe infant morbidity and mortality. In the United States, there are racial and ethnic differences in the prevalence of PTB and LBW. We investigated the association between PTB and LBW with prenatal mercury (Hg) exposure and season of conception in an urban immigrant community in Brooklyn, New York. We recruited 191 pregnant women aged 18–45 in a Brooklyn Prenatal Clinic and followed them until delivery. Urine specimens were collected from the participants during the 6th to 9th month of pregnancy. Cord blood specimens and neonate anthropometric data were collected at birth. We used multivariate logistic regression models to investigate the odds of LBW or PTB with either maternal urinary mercury or neonate cord blood mercury. We used linear regression models to investigate the association between continuous anthropometric outcomes and maternal urinary mercury or neonate cord blood mercury. We also examined the association between LBW and PTB and the season that pregnancy began. Results showed higher rates of PTB and LBW in this cohort of women compared to other studies. Pregnancies beginning in winter (December, January, February) were at increased odds of LBW births compared with births from pregnancies that began in all other months (OR7.52 [95% CI 1.65, 34.29]). We observed no association between maternal exposure to Hg, and either LBW or PTB. The apparent lack of association is consistent with other studies. Further examination of seasonal association with LBW is warranted