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Preeclampsia is a leading cause of maternal and fetal morbidity and mortality. Bb, the active fragment of complement factor B (fB), has been reported to be a predictor of preeclampsia. However, conflicting results have been found by some investigators. We hypothesized that the disagreement in findings may be due to the racial/ethnic differences among various study groups, and that fB activation is significant in women of an ethnic minority with preeclampsia. We investigated the maternal and fetal levels of Bb (the activated fB fragment) in pregnant women of an ethnic minority with or without preeclampsia. We enrolled 291 pregnant women (96% of an ethnic minority, including 78% African-American). Thirteen percent of these were diagnosed with preeclampsia. Maternal venous blood was collected from all participants together with fetal umbilical cord blood samples from 154 deliveries in the 291 women. The results were analyzed using the Mann-Whitney U test and multivariate analyses. Maternal Bb levels were significantly higher in the preeclamptic group than in the nonpreeclamptic group. Levels of Bb in fetal cord blood were similar in both groups. Subgroup analyses of African-American patients' results confirmed the study hypothesis that there would be a significant increase in Bb in the maternal blood of the preeclamptic group and no increase in Bb in the fetal cord blood of this group. These results suggest that a maternal immune response through complement fB might play a role in the development of preeclampsia, particularly in African-American patients.

Polycystic ovary syndrome (PCOS) patients are known to have a high incidence of insulin resistance and glucose intolerance and tend to be at eventual high risk of hypertension ,diabetes mellitus and cardiovascular disease. It has been repeatedly shown that a low serum ionized magnesium (Mg2+) and a high ionized calcium to magnesium (Ca2+/Mg2+) ratio is often associated with insulin resistance ,cardiovascular problems ,diabetes mellitus and hypertension. We were therefore interested in assessing the serum divalent cation profile of PCOS patients compared with that of normal women of similar age. We found significantly lower serum Mg2+ and total magnesium and a significantly higher serum Ca2+/Mg2+ ratio in the PCOS patients compared with the controls. No correlation was found ,however ,between the serum concentrations of steroid hormones (estrogen ,progesterone and testosterone) ,or any of the cations in the PCOS patients or the controls.

Background Multiple endocrine neoplasia (MEN) type 2a is an autosomal dominant syndrome caused by specific proto-oncogene mutations characterized by medullary carcinoma of the thyroid, pheochromocytoma, and, occasionally, multiglandular parathyroid hyperplasia, which rarely complicates pregnancy. Secondary diabetes rarely has been reported in association with principal endocrinopathies complicating pregnancy. Case A 34-year-old primiparous woman with recently diagnosed gestational diabetes had repeated episodes of dizziness at 30 weeks of gestation, initially attributed to glyburide. Continued episodes of dizziness and later-appearing bouts of severe headache, palpitations, diaphoresis, severe hypertension, and marked tachycardia led to diagnosis and management of MEN type 2a complicating pregnancy. Conclusion Patients with MEN type 2a complicating pregnancy may present with gestational diabetes.

First-trimester screening for fetal aneuploidy using nuchal translucency (NT), pregnancy-associated plasma protein A, free or total β-hCG, and maternal age constitutes a very effective screening test for fetal Down syndrome. We describe a case in which a patient presented at 14 weeks' gestation with an acute abdomen 1 week after first-trimester screening (including NT measurement) performed elsewhere, which was negative for trisomies 21 and 18. Sonographic examination revealed an interstitial pregnancy with a singleton fetus with present cardiac activity, which had not been noted 1 week earlier at the time of earlier transabdominal NT measurement. This case indicates that successful acquisition of a NT measurement during first-trimester screening for fetal aneuploidy does not negate the rare possibility of an unusual ectopic pregnancy. © 2008 Wiley Periodicals, Inc. J Clin Ultrasound, 2009

The differential diagnosis of prenatally diagnosed adrenal masses includes neuroblastoma, adrenal hemorrhage, adrenal and cortical renal cysts, adrenal adenoma and carcinoma, subdiaphragmatic pulmonary sequestration, Beckwith-Wiedemann syndrome, duplication of the renal system, Wilms tumors, congenital mesoblastic nephroma, and mesenteric and enteric duplication cysts. 1-5 The worldwide annual incidence of childhood adrenal cortical neoplasms ranges between 0.3 and 0.38 per 1 million children younger than 15 years. 6 These neoplasms are even more unusual among infants, with only 23 cases reported in the literature. 6 We present the first report of prenatal sonographic findings of a fetus with adrenal cortical adenoma.

Conjoined twins, rare complications of monozygotic twinning, occur in approximately 1% of monozygotic twins or between 1 per 100,000 and 1 per 250,000 live births. 1,2 Thoracopagus is the most common type of conjoined twins, with approximately 75% of such cases having conjoined hearts. 3 Reported cases of first-trimester transvaginal sonographic diagnosis of conjoined twins have almost uniformly involved gestational ages ranging between 11 and 14 weeks. 4-11 Earlier diagnosis is uncommon, yet single cases have been reported at 9 and 10 weeks, respectively. 12-17 An additional case of conjoined twins in a triplet pregnancy at 10.5 weeks' gestation was reported by Sepulveda et al. 18 We report an unusual case in which transvaginal color Doppler imaging confirmed the presence of thoracopagus, suspected during real-time sonography at 7 weeks' gestation.

Objective The objective of the study was to assess the incidence of gestational diabetes among black women according to various cut-off values of the glucose challenge test. Study design We performed a retrospective chart review of black patients who had a 50-g, 1-hour glucose challenge test between 24 and 28 weeks' gestation of 130 mg/dL or higher followed by a 100-g, 3-hour glucose tolerance test. Results were categorized in 10-mg/dL increments. Gestational diabetes was diagnosed by 2 or more abnormal values using the Carpenter-Coustan criteria. Results The study included 387 patients. The incidence of gestational diabetes diagnosed overall in all patients with a glucose challenge test of 130 mg/dL or higher was 31.2%. The incidence of gestational diabetes in individuals with a challenge test in the range of 130 to 140 mg/dL was 10.7%. The incidence of gestational diabetes with a screening test of 180 mg/dL or higher was 72.0%. Conclusion Our data support the use of 130 mg/dL as the threshold for a positive glucose challenge test and suggest the use of a glucose tolerance test to confirm the diagnosis of gestational diabetes for screening values up to 200 mg/dL.

Spontaneous antepartum septostomy occurring in monochorionic diamniotic twins is extremely rare. We present a case in which prenatal sonography at 26 weeks' gestation depicted a monochorionic diamniotic twin gestation with concordant fetal growth and findings suggestive of a true knot of the umbilical cord. At Cesarean delivery at 34 weeks' gestation, spontaneous antepartum septostomy with entanglement of the two separate umbilical cords was noted. This case suggests that the differential diagnosis of findings considered consistent with a true knot of the umbilical cord in monochorionic diamniotic twin gestations, should include spontaneous antepartum septostomy and umbilical cord entanglement.

The reported incidence of a true knot of the umbilical cord is approximately 1.2% of all deliveries. 1 , 2 Prenatal sonographic diagnoses of cases of a true knot of the umbilical cord have been reported infrequently. 3 - 6 RamOn y Cajal and Martinez 7 recently reported characteristic sonographic findings of this condition, in which a detailed investigation disclosed a transverse section of the umbilical cord surrounded by a loop of umbilical cord. This finding, noted in 5 cases, was termed the "hanging noose" sign. We present an unusual case in which 2 true knots of the umbilical cord were noted by power Doppler sonography in close proximity to each other at 33 weeks' gestation and were confirmed as separate true knots of the umbilical cord by 3-dimensional sonographic imaging.

Short umbilical cords are associated with fetal anomalies, often including those with decreased or absent fetal movement, fetal akinesia/hypokinesia sequence, and restrictive dermopathies and aneuploidy. In normal fetuses, abnormally short umbilical cords have been associated with an increased risk of umbilical vessel hematomas, thrombosis, rupture, thrombocytopenia, cord compression, variable fetal heart rate decelerations, instrumental and operative deliveries, and fetal demise. We report a 24-year-old gravida 2, para 0 with a concordant dichorionic twin gestation, at 26 weeks' gestation, in whom sonography depicted fetuses with normal-appearing anatomy as well as short umbilical cord of the 1st twin. Increased fetal surveillance was conducted. Following delivery at 36 weeks' gestation, the presence of a short umbilical cord of the 1st twin measuring 19 cm was confirmed. Systematic review of the literature confirms that this is the first report of prenatal diagnosis of a short umbilical cord in an otherwise normal fetus. © 2009 Wiley Periodicals, Inc. J Clin Ultrasound 2010

Germ cell tumors are most commonly located within the gonads. 1 Rare extragonadal locations of these tumors include the retroperitoneum, mediastinum, sacrococcygeum, and central nervous system and are considered to result from aberrant migration of germ cells from the yolk sac during fetal development. 1―4 We present transvaginal sonographic and magnetic resonance imaging (MRI) findings of a massive epidermoid cyst extending from the pelvis to the buttock.

Brenner tumors, benign transitional cell tumors of the ovary, constitute approximately 3.1% of ovarian epithelial neoplasms.' The mean patient age is 50 years. Most tumors are 2 cm or smaller, but occasionally they are large and may exceed 10 cm.' Microscopically, the characteristic feature consists of sharply demarcated epithelial cell nests embedded in a dense fibrous stroma.' Hyalinized areas are common, and dystrophic calcification is present in 50% of cases, often in the hyalinized areas. 1 Sonographic findings of benign Brenner tumors have been described and consist of solid hypoechoic masses, with calcifications noted at times. 2,3 In a recent study pertaining to the sonographic and computed tomographic features of this tumor including 22 women with 25 ovarian Brenner tumors, 16 of 25 (64%) were found incidentally. 3 We present an unusual case of a Brenner tumor complicating pregnancy and a description of the color Doppler sonographic features of this tumor in pregnancy.

Background Methicillin-resistant Staphylococcus aureus (MRSA) is an extremely rare etiology of chorioamnionitis. Case A young primigravida, with sickle cell (Hb SS) disease and beta thalassemia presented at 37 weeks of gestation with fever, chills, and lower abdominal pain in the presence of intact fetal membranes, 10 days after recurrent marsupialization of a Bartholin abscess. Overt clinical chorioamnionitis was diagnosed. The patient received intravenous triple antibiotics and delivered by immediate cesarean. Maternal blood, uterine, placental and neonatal nares, external auditory canal, and umbilical cord stump cultures all yielded MRSA. Both the mother and infant received intravenous vancomycin and did well. Conclusion Our case and the literature suggest that it may be prudent to consider MRSA when contemplating the possibility of chorioamnionitis in the presence of intact fetal membranes, especially in gravidas with recurrent admissions or minor surgical procedures or who are hospital staff.

Received December 3, 2008, from the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology (D.M.S., M.D., M.S., M.K., S.Y., O.A.), and Department of Radiology (H.Z.), State University of New York, Downstate Medical Center, Brooklyn, New York USA; and Division of Obstetric and Gynecologic Ultrasound, Department of Obstetrics and Gynecology, New York University Medical Center, New York, New York USA (I.E.T.-T.). Revision requested December 3, 2008. Revised manuscript accepted for publication December 5, 2008. Address correspondence to David M. Sherer, MD, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, State University of New York, Downstate Medical Center, 445 Lenox Rd, Box 24, Brooklyn, NY 11203-2098 USA. E-mail: dmsherer@aol.com Abbreviations MR, magnetic resonance n 18 year-old nulliparous patient was followed during pregnancy at the State University of New York Downstate Medical Center. Results of first-trimester nuchal translucency and serum screening and second-trimester serum screening for aneuploidy were negative. Sonography at 22 weeks depicted a singleton male fetus with appropriate-for-gestational-age fetal biometric measurements, a normal amniotic fluid volume, and a single nuchal cord. The fetal anatomy was normal other than the finding of a prominent anechoic structure measuring 2 ×1 cm within the off-center, left aspect of the fetal neck (Figures 1–3). The superficial anterior, posterior, and lateral aspects of the fetal neck area were normal, as was the thyroid gland. Specifically, no masses other than the central cystic lesion were noted. Color Doppler and power Doppler imaging did not detect any flow within the cystic structure. Fetal echocardiographic findings were normal. The patient was offered but declined amniocentesis. She was seen at 4-week intervals, at which the above findings continued to be present throughout gestation. Vaginal delivery was not considered contraindicated, but at 39 weeks’ gestation after arrest of the active phase of labor, the patient underwent a transverse lower segment cesarean delivery. The vigorous male neonate weighed 2810 g and was assigned Apgar scores of 9 and 9 at 1 and 5 minutes, respectively. The umbilical artery pH was 7.32, and the base excess was 0.8. The patient’s postoperative course was uneventful other than endometritis, for which she received intravenous antibiotics. Physical examination of the neonate disclosed no dysmorphic features or abnormal findings. A normal 46,XY karyotype was shown. The neonate received normal feeds and underwent imaging assessment of the cervical lesion. Neonatal sonography depicted a cystic structure at the lower aspect of the neck measuring approximately 1 cm in diameter. No evidence was seen of fluid within the

OBJECTIVE The purpose of this study was to create reference range nomograms of the axial transverse diameter of the fetal foramen magnum (TDFM) between 14 and 40 weeks' gestation. METHODS This cross-sectional study included pregnant patients between 14 and 41 weeks' gestation. Inclusion criteria consisted of well-established dates (confirmed by early sonography) and nonanomalous singleton fetuses with intact amniotic membranes. Sonographic measurements included biparietal diameter, head circumference, abdominal circumference, femur length, humerus length, transcerebellar diameter, and sonographically estimated fetal weight. Values of the TDFM were each calculated as the mean of 3 separate measurements. The 5th, 50th, and 95th percentiles were estimated at each week of gestational age (GA) by least squares regression for the mean and SD of the TDFM as functions of GA. R(2) and associated P values for the relationships between the TDFM and other biometric measurements were calculated. RESULTS The study included 602 consecutive patients meeting the inclusion criteria. The mean maternal age +/- SD was 27.5 +/- 6.4 years; median gravidity, 3 (range, 1-12); and median parity, 1 (range, 0-7). The mean TDFM was 13.5 +/- 3.7 mm. The reference curve formulas for the mean and SD of the TDFM (mm) were TDFM = -12.58 + GA/0.5616 - GA(2)/24.9 + GA(3)/2430.7, and SD(TDFM) = 1.05 - GA/19.4 + GA(2)/588.8. The TDFM correlated significantly and strongly with biparietal diameter, head circumference, abdominal circumference, humerus length, femur length, transcerebellar diameter, and estimated fetal weight (all R(2) >or= 0.90; all P < .0001). CONCLUSIONS We present reference range nomograms of the TDFM between 14 and 40 weeks' gestation.

Abdominal pregnancy is a rare condition in which the fetus and placenta are located within the peritoneal cavity. Sonographic findings include visualization of the fetus separate from the uterus, failure to visualize the uterine wall between the fetus and urinary bladder, close approximation of fetal parts to the maternal abdominal wall, eccentric position or abnormal fetal attitude, and visualization of extrauterine placental tissue. We present an unusual case in which mid-trimester transabdominal color Doppler sonographic findings depicted unusual maternal vasculature in the placental periphery leading to the diagnosis of abdominal pregnancy. Postpartum maternal angiography confirmed these vessels as abnormal maternal arterial perfusion of the extrauterine placenta emanating from the uterine arteries and inferior epigastric arteries. Systematic review of the literature confirms that this is the first report of such sonographic manifestations of an abdominal pregnancy.

Bilateral ovarian enlargement may reflect benign or malignant processes of the ovary. Benign causes of ovarian enlargement include luteomas, tumors such as mature cystic teratomas, fibrothecomas, cystadenomas and rare conditions including capillary hemangioma and massive edema of the ovaries. Ovarian malignancies include epithelial, stromal and germ-cell tumors. Primary malignancies that may exhibit metastases to the ovaries include gastrointestinal, breast and soft tissue tumors such as lymphoma. We present an unusual case in which a patient presenting with weakness and mild lower abdominal and pelvic pain was noted at sonography to have bilaterally enlarged ovaries with features similar to those of massive ovarian edema as described previously, which has been associated with venous and lymphatic obstruction. Subsequent computerized tomography (CT) imaging depicted a large retroperitoneal tumor, CT-guided biopsy of which revealed diffuse large B cell lymphoma. The patient responded well to chemotherapy with significant shrinkage of the tumor, and reappearance of normal findings on ovarian sonography. This case demonstrates that bilaterally enlarged ovaries may be the first clinical evidence of a large retroperitoneal tumor and that in such cases CT imaging may be warranted.

Objective The widely applied transcerebellar diameter (TCD) obtained at axial cranial imaging, measures the distance between the lateral aspects of the cerebellum and incorporates the width of the cerebellar vermis. Our objective was to create reference ranges of axial fetal cerebellar hemisphere circumference (CHC) and area (CHA), independent of the cerebellar vermis, throughout gestation. Methods This cross-sectional study involved pregnant patients between 14 and 41 weeks of gestation. Inclusion criteria consisted of well-established dates (confirmed by early ultrasound), non-anomalous singleton fetuses and intact amniotic membranes. Sonographic measurements included biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC), femur length (FL), humerus length (HL), TCD, and estimated fetal weight (EFW). Values of axial fetal CHC and CHA were each calculated as the mean of three separate measurements. The 5th, 50th and 95th centiles were estimated at each week of gestational age (GA) by least-squares regression for the mean and standard deviation (SD) of the CHC and CHA as functions of GA. r2 and associated P-values for the relationships of CHC and CHA with other sonographic biometric measurements were calculated. Results The study included 651 consecutive patients. All attempts at obtaining axial fetal CHC and CHA were successful. Mean maternal age was 27.3 ± 6.7 years, median gravidity was 1 (range 1–16), and median parity was 1 (range 0–6). Mean CHC (cm) throughout gestation was modeled as − 2.091 + 0.2563 × GA (weeks) (SD = − 0.075 + 0.0164 × GA), and mean CHA (cm2) was modeled as 0.245–0.0765 × GA+ 0.00506 × GA2 (SD = 1.167 − 0.1565 × GA + 0.006785 × GA2 − 0.00008028 × GA3). Fetal axial CHC and CHA correlated significantly and strongly with BPD, HC, AC, HL, FL, TCD and EFW (all R2 values were ≥ 0.95, and all P-values were < 0.001). Conclusion Nomograms of axial fetal cerebellar hemisphere circumference and area throughout gestation, independent of the cerebellar vermis, have been provided. Copyright © 2006 ISUOG. Published by John Wiley & Sons, Ltd.

Obstruction of the lower female genital tract leading to proximal dilatation and development of hematocolpos, hematotrachelos, and hematometra is most commonly a result of congenital abnormalities. 1-3 These conditions include an imperforate hymen, a complete transverse vaginal septum, and vaginal and, rarely, cervical atresia. 1-3 Acquired obstruction of the lower female genital tract is rare. Etiologies of such acquired lesions include iatrogenic trauma to the uterine cervix such as cone biopsies, loop electrosurgical procedures, dilation and curettage, obstetric lacerations, cervical or endometrial carcinoma, and radiation therapy. 4-8 Spontaneous obstruction is extremely rare yet has been reported recently. 9 We describe an unusual case in which sonographic findings of marked spontaneous hematometra and hematotrachelos were depicted in an adolescent with dysfunctional uterine bleeding.

Preeclampsia is uncommon prior to 24 weeks gestation and has been associated with partial and complete hydatidiform moles. We present an unusual case in which a patient was diagnosed with preeclampsia at 17 weeks gestation. Ultrasound findings were consistent with a partial hydatidiform mole. Within 24 hours of the onset of symptoms, the patient developed severe hemolysis, elevated liver enzymes, and low platelet count syndrome, with a platelet count of 20 x 10 (9) cells/L. Termination of pregnancy was performed with rapid resolution of signs, symptoms, and laboratory abnormalities. Triploid 69,XXY was confirmed at karyotype analysis. This case demonstrates the acuteness in which life-threatening maternal conditions can arise with this uncommon complication of pregnancy, and the importance of correct identification of the characteristic ultrasonographic findings associated with a partial hydatidiform mole.

We present an unusual case in which a 23-year-old nulliparous patient was noted to have bilateral multicystic adnexal masses at 21 weeks gestation. Subsequent severe nausea, vomiting, and hyperglycemia with a serum glucose level of 450 mg/dL led to the diagnosis of gestational diabetes. Gradual development of marked maternal virilization ensued and was associated with a serum testosterone level of 4030 ng/mL (free testosterone level of 224 pg/mL), with normal serum dehydroepiandrostendione, estriol, and cortisol levels, leading to the diagnosis of hyperreactio luteinalis. Following vaginal delivery at 38 weeks gestation, gradual and complete spontaneous resolution of signs, symptoms, adnexal masses, diabetes, and testosterone levels were documented.

A high association between trisomy 21 and absence of the nasal bone at first-trimester sonography (11-14 weeks' gestation) has been established. 1-3 The presence or absence of the nasal bone was found to be independent of other maternal or fetal variables and thus may be added to other sonographic markers for prenatal detection of trisomy 21. 3 Bromley et al, 4 later Bunduki et al, 5 and others 6 confirmed a mid-second-trimester (15-22 weeks' gestation) association of an absent or hypoplastic nasal bone and trisomy 21. In addition, an absent nasal bone at the 11- to 14-week sonographic scan has been associated with other fetal aneuploidies. 7,8 Cicero et al 7 reported an absent nasal bone in 161 (66.9%) of 242 fetuses with trisomy 21, 48 (57.1%) of 84 fetuses with trisomy 18, 7 (31.8%) of 22 fetuses with trisomy 13, 3 (8.8%) of 34 fetuses with 45,XO, and 4 (8.3%) of 48 fetuses with other aneuploidy defects (XXX, XXY, XYY, and triploidy). The association of an absent or hypoplastic nasal bone and aneuploidies other than trisomy 21 was confirmed by Odibo et al 8 We report a case in which sonographic depiction of an absent nasal bone at 20 weeks' gestation led to amniocentesis and the detection of a fetus with cri du chat (5p-) syndrome.

Objective To create a nomogram of fetal clavicle length (CL) throughout gestation. Methods Cross-sectional study of patients between 14 and 42 weeks' gestation. Inclusion criteria consisted of well-established dates (consistent with early ultrasound), singleton, non-anomalous fetuses, and intact amniotic membranes. Sonographic measurements included biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC), femur length (FL), humerus length (HL) and sonographically estimated fetal weight (SEFW). For every case, the average of three separate measurements of the CL was used. The 5th, 50th and 95th centiles were obtained by least squares regression. Pearson's correlation coefficient and associated P-values for the relationships between CL and other biometric measurements were calculated. The data were compared to a nomogram of the CL generated in 1985 from the measurement of 85 fetuses. Results A total of 623 consecutive patients were studied. In all but three cases, CL was successfully measured. Mean maternal age was 27.7 ± 6.2 years, median gravidity 3 (range, 1–14) and median parity 1 (range, 0-9). Mean CL (mm) = −75.30 + 32.70*ln(GA) and SD = −0.41 + 0.08328*GA, where ln represents the natural logarithm and GA the gestational age in weeks. Fetal CL correlated significantly and strongly with BPD, HC, AC, HL, FL and the logarithm of SEFW, with Pearson correlation values of 0.973, 0.977, 0.976, 0.979, 0.977 and 0.979, respectively (all P < 0.001). Measurements according to comparable 1985 data were consistently substantially below the present data (smaller CL for any given GA except below 17 weeks' gestation). Conclusions We propose a new nomogram of CL, which differs significantly from the previously published nomogram. We suggest that the present data reflect the use of high-resolution ultrasound technology and propose that these data, based on a large number of fetuses, replace the previous nomogram. We also suggest that the ‘1 mm = 1 week’ rule of thumb should no longer be used, since it can be erroneous by as much as 6 weeks. Copyright © 2006 ISUOG. Published by John Wiley & Sons, Ltd.

An increased incidence of thrombotic thrombocytopenic purpura has been reported among human immunodeficiency virus-infected patients or those with acquired immunodeficiency syndrome (AIDS). Despite this association, hitherto only a single case of thrombotic thrombocytopenic purpura has been reported in an HIV-infected patient during pregnancy. We describe a young multiparous patient with long-standing AIDS who presented with lower abdominal pain. Following findings of thrombocytopenia, microangiopathic hemolytic anemia, renal failure, low-grade fever, and mental status changes, thrombotic thrombocytopenic purpura was diagnosed after initially considering the diagnosis of severe preeclampsia, and the patient was delivered by cesarean section. The patient required multiple plasma exchanges during a protracted postpartum course, and was discharged in good health. This first report of thrombotic thrombocytopenic purpura and AIDS in pregnancy demonstrates that when encountering preeclampsia in patients with AIDS, thrombotic microangiopathy should be strongly considered. In addition, these patients may exhibit an attenuated response to plasma exchange therapy and despite previous reports in nonobstetric patients, a favorable outcome is attainable in these critically ill patients.

Uterine contraction-associated accelerations of the maternal heart rate are considered to reflect both a transient contraction-related increase in cardiac output and endogenous catecholamine secretion. Uterine contraction-associated decelerations of the maternal heart rate are rare and remain unexplained. A young multiparous patient with systemic lupus erythematosus (postrenal transplant for lupus nephropathy-related renal failure) presented in early labor at 39 weeks gestation, prior to elective repeat cesarean section. Intrapartum continuous maternal heart rate monitoring demonstrated repetitive uterine contraction associated decelerations of the maternal heart rate of 60 beats per minute, each lasting 2 minutes, simulating nonreassuring fetal status. Simultaneously depicted fetal heart rate was reassuring. This case demonstrates an unusual marked early intrapartum affect of uterine contractions upon the maternal heart rate. In addition, this case illustrates the potentially dangerous similarity of an intrapartum maternal heart rate to an abnormal fetal heart rate pattern, and emphasizes the importance of correct identification of the maternal and fetal heart rates, respectively.

Dandy-Walker malformation accounts for approximately 5% to 10% of congenital hydrocephalus cases and consists of 3 major abnormalities: cystic dilatation of the fourth ventricle, complete or partial agenesis of the cerebellarvermis, and hydrocephalus. 1,2 It appears that the development of this condition is primarily a delay or total failure of the foramen of Magendie to open, allowing a buildup of cerebrospinal fluid with development of the cystic dilatation of the fourth ventricle. Dandy-Walker malformation has been reported in a wide variety of syndromes, including various mendelian disorders, chromosome abnormalities (trisomies 9, 13, 18, and 21, triploidy, and others), and antenatal exposure to teratogens (rubella, cytomegalovirus, toxoplasmosis, warfarin sodium, alcohol, isotretinoin, and maternal diabetes).2 Associated structural anomalies, which may occur in between 69% and 75% of cases, include intracranial abnormalities (agenesis of the corpus callosum and defects of neuronal migration), congenital cardiac disease (atrial and ventricular septal defects, atrioventricular canal defect, and pulmonary stenosis), renal anomalies, facial clefts, and syndactyly. 3,4 We present an unusual case in which Dandy-Walker malformation was diagnosed ultrasonographically in a fetus at 34 weeks' gestation, who subsequently had a large unilateral intraventricular hemorrhage and marked neonatal thrombocytopenia after cesarean delivery. The association of an antepartum intraventricular hemorrhage in a fetus with Dandy-Walker malformation is unusual and may be worthy of further investigation.

The cavum septum pellucidum is a fluid-filled cavity located between the membranes of the septi pellucidi, which should always be visualized sonographically in normal fetuses between 18 and 37 weeks gestation and in approximately 50% of term infants. The cavum vergae, a cavity within the septum pellucidum, is located posterior to an arbitrary vertical plane formed by the columns of the fornix. We present a case in which markedly dilated cavum septum pellucidum et vergae noted at 29 weeks gestation was associated with midgut malrotation and volvulus, and review the literature pertaining to this unusual prenatal ultrasonographic diagnosis.

It is known that ovarian hyperstimulation and in vitro fertilization are accompanied by a steady increase in circulating estrogen and progesterone far beyond what is normal for young women. We have recently demonstrated that the biologically active fractions of calcium and magnesium in blood are altered depending on when in the menstrual phase a blood sample is drawn in normal cycling women. The serum ionized Ca/Mg ratio is also altered in accordance with the menstrual cycles. This suggests that the sex steroid hormones may modulate serum levels of ionized Mg and the ionized Ca/Mg ratio. We therefore studied the relationships between sex steroid hormones and the concentrations of ionized magnesium and calcium in the blood of hyperstimulated patients. We were able to demonstrate that with each increment in estrogen, a decrease in ionized Mg occurred, and as the progesterone rose in the blood, the ionized Ca/Mg ratio increased. Our results support the idea that serum estrogen and progesterone levels in women modulate the blood levels of circulating ionized Mg and the serum ionized Ca/Mg ratio.

Objective: To determine the serum concentrations of the sex hormones with respect to the concentrations of the biologically active fractions of magnesium (Mg) and calcium (Ca) in healthy young men and to compare them with those in young and older women. Design: Controlled clinical study. Setting: An academic research environment. Patient(s): Twenty-five healthy young male volunteers. Intervention(s): None. Main Outcome Measure(s): Concentrations of the sex steroid hormones testosterone, estrogen, and progesterone, and levels of ionized Ca (Ca 2+ ) and Mg (Mg 2+ ) were measured in the serum of healthy young men. These levels were compared with those in young women at different phases of the menstrual cycle and with those in older women. Result(s): The Mg 2+ and total Mg concentrations in young men were not different from those during the follicular phase in young women or from the mean concentrations in menopausal women. The Ca 2+ levels in young men were similar to the levels in young women during the follicular phase but significantly lower than the levels in older women. The Mg 2+ concentration in the young men was directly and significantly related to the progesterone level, and the Ca 2+ /Mg 2+ ratio was inversely related to the progesterone level. Conclusion(s): Progesterone may be a more important steroid hormone in men than previously believed.

Objective. The purpose of this study was to create reference range nomograms of the axial fetal neck circumference (FNC) and fetal neck area (FNA) throughout gestation. Methods. This prospective crosssectional study involved pregnant patients between 14 and 40 weeks’ gestation. Inclusion criteria consisted of well-established dates (confirmed by early sonography) and nonanomalous singleton fetuses with intact fetal membranes. Sonographic measurements included biparietal diameter, head circumference, abdominal circumference, femur length, humerus length, transcerebellar diameter, and sonographically estimated fetal weight. Axial FNC and FNA values were calculated as means of 3 separate measurements. The 5th, 50th, and 95th percentiles were estimated at each week of gestational age (GA) by least squares regression for the mean and SD of the FNC and FNA as functions of GA. R 2 and associated P values for the relationships between the FNC, FNA, and other sonographic biometric measurements were calculated. Results. The study included 720 consecutive patients. The mean maternal age ± SD was 27.3 ± 6.6 years; median gravidity, 3 (range, 1‐13); and median parity, 1 (range, 0‐10). The following equations were devised: mean FNC (centimeters) = ‐11.85 + 1.687 × GA (weeks) ‐ 0.043 × GA 2 + 0.0004951 × GA 3 ; SD FNC = 3.15 ‐ 0.3823 × GA + 0.01733 × GA 2 ‐ 0.0002179 × GA 3 ; mean FNA (square centimeters) = 37.29 ‐ 7.0 × GA + 0.4717 × GA 2 ‐ 0.01245 × GA 3 + 0.0001222 × GA 4 ; and SD FNA = 7.08 ‐ 0.9413 × GA + 0.04135 × GA 2 ‐ 0.0004829 × GA 3 . Both the FNC and FNA

Prenatal mercury exposure and its fetotoxic effects may be of particular concern in urban immigrant communities as a result of possible contributing cultural factors. The most common source of exposure in these communities is ingestion of fish and shellfish contaminated with methylmercury. Other sources of exposure may occur in ritualistic practices associated with Hispanic and Caribbean-based religions. This study 1) assessed total mercury levels in both random urine specimens from pregnant women, and in cord blood; and 2) examined environmental sources of exposure from a convenience sample in a predominantly Caribbean immigrant population in Brooklyn, New York. A questionnaire designed in collaboration with health professionals from the Caribbean community assessed the frequency of fish consumption, ritualistic practices, occupational exposures, and use of dental amalgams and mercury-containing skin and household products. The geometric mean for total mercury in cord blood was 2.14 μg L(-1) (95%CI: 1.76-2.60) (n = 78), and 0.45 μg L(-1) (95%CI: 0.37-0.55) (n = 183) in maternal urine corrected for creatinine (μg g(-1)). Sixteen percent of cord blood mercury levels exceeded the estimated equivalent of U.S. Environmental Protection Agency's Reference Dose (5.8 μg L(-1) blood). Predictors of cord blood mercury included maternal fish consumption and foreign birth of the mother. Predictors of urine mercury included foreign birth of the mother, number of dental amalgams, and special product use. There were no reports of mercury use in ritualistic practices or in cosmetics; however some women reported use of religious medals and charms. This study characterized risk factors for mercury exposure in a sample of urban, predominantly Caribbean-born blacks. Findings may help target interventions in this population, which might include appropriate fish selection and consumption frequency during pregnancy, and safe handling of mercury-containing products in the home.

In a previous study of a cohort of pregnant women (mostly whites, with 4.6% preeclampsia), complement factor B, a central molecule of alternative complement pathway, is observed as a predictor of preeclampsia in early pregnancy. Whether this observation could be applied to other populations is unknown. Further, the status of factor B in the fetal circulation of preeclampsia is unclear. We investigated these important questions by examining a cohort of pregnant women with high risk of preeclampsia. Fifty pregnant women (mostly African Americans, with 14% preeclampsia) were enrolled. Preeclampsia were diagnosed before delivery. Blood samples were collected from maternal and fetal umbilical cord blood immediately after delivery. Plasma Bb levels, the active fragment of factor B, were quantified by ELISA. We found that maternal plasma Bb levels were significantly higher in women with preeclampsia than those of normal pregnancy (increased 72%, P=0.02). In addition, Bb levels in the fetal cord blood of preeclampsia group were also significantly higher than those of normal (increased 92%, P=0.03). In summary, in a cohort of minority pregnant women with high risk of preeclampsia, complement factor B is activated in both maternal and fetal circulations during preeclamptic pregnancy. Activation of alternative complements may contribute to the systemic inflammatory response in both mothers and fetus.

Objective: To evaluate the sensitivity, specificity, positive predictive value and negative predictive value to determine a low central venous pressure (0–5 mmH2O) using ultrasound to determine the central venous pressure compared to invasive central venous pressure measurement. Method: Indigent pregnant South Africans with severe maternal disease managed in a tertiary setting. Since 2003 all the obstetric patients who required the placement of a central venous pressure line or a Swan-Ganz catheter were asked to participate in a study comparing ultrasonic evaluation of the heart with the invasive monitoring of the heart. If the patient agreed, the catheters were placed and the measurements were obtained, thereafter an ultrasonographic examination of the patient’s heart was performed. During this examination the diameter of the inferior vena cava was measured 2.5 cm from the entrance into the atria. The percentage of collapse during inspiration was also evaluated and according to this, the central venous pressure was estimated. This value was correlated with the value obtained with the invasive technique. The measurements were initially performed using a standard cardiac probe. Currently the measurement is performed using the standard abdominal probe that is used for normal obstetric ultra sound examinations. (The technique will be demonstrated using a video presentation). Results: A total of 33 measurements were obtained. The sensitivity was 92%, specificity was 95%, positive predictive value was 92% and the negative predictive value was 95% and the accuracy was 94% for the central venous pressure between 0 and 5 mmH2O. Conclusion: Non-invasive CVP measurements using standard obstetric ultrasound equipment can be used to predict a low central venous pressure in the place of invasive CVP monitoring. This can be valuable in managing an ill obstetric patient when it is not safe to place a CVP line. OP13.07 Nomograms of axial fetal cerebellar hemisphere circumference and area throughout gestation