- Email: [email protected]
Fetal heart block caused by cytomegalovirus
Volume Number
136 7
Communications
the young and healthy population represented by IUD users, the also well-established association of bleeding and genital cancer is frequently forgotten. Genital malignancy has rarely been reported in association with the use of an IUD.’ A recent technical bulletin of the American College of Obstetricians and Gynecologists does not specifically mention this possibility while discussing abnormal bleeding with IUDs.’ In the first case, a 43-year-old woman was sent home twice with reassurance that her bleeding was secondary to the IUD. If not for the pathologic examination of the IUD, the diagnosis of malignancy would have been even further delayed. In the second case, this 24-year-old woman had an IUD inserted with a cervical lesion present. The clinical acumen of a senior attending physician was necessary to obtain the diagnosis. In addition to the mandatory Papanicolaou smear, we feel that the key to the diagnosis of a genital malignancy in IUD users is a high index of suspicion and a routine pathologic processing of the tissue attached to the IUD, which we have found to be almost always present. With these safeguards, early diagnosis of malignancy is greatly facilitated. REFERENCES
Harrison, R. F.: Adenocarcinoma of the uterine body following use of intrauterine contraceptive device, Ir. J. Med. Sci. 140:407, 1971. 2. The intrauterine device, ACOG Technical Bulletin, No. 40, June, 1976. 1.
Fetal heart block caused by cytomegalovirus P. E. LEWIS
II,
COMMANDER
(MC)
USN
R. C. CEFALO, CAPTAIN
(MC)
USN
A. L. ZARITSKY, LIEUTENANT
National CONGENITAL
Naval
(MC)
Medical HEART
occurs in approximately
USNR
Center,
Bethesda,
Maryland
of clinical significance five cases per 1,000 live births.
DISEASE
Presented at the Armed Forces District Meeting of the American College of Obstetricians and Gynecologists, Washington, D. C., October, 1978. The opinions or assertions contained herein are those of the authors and are not to be construed as official or reflecting the views of the Navy Department or of the Naval Service at large. Reprint requests: Commander P. E. Lewis II (MC) USN, Naval Regional Medical Center, Obstetrics and Gynecology Service, Portsmouth, Virginia 23708.
in brief
967
In most of these cases, no specific etiology can be determined. Viral infections during gestation have been associated with congenital heart disease in cases of rubella, Coxsackie B, and mumps viruses. A causeand-effect relationship appears valid for the rubella virus but is unproven for other viruses.’ Cytomegalovirus has been proven to cause congenital defects, including microcephaly, hydrocephaly, microphthalmia, cerebral calcification, and hepatosplenomegaly. Only infrequently have cardiovascular anomalies been associated with cytomegalovirus.’ In this report, congenital heart block was diagnosed at 28-weeks gestation with persistence after delivery at 39 weeks, and subsequent neonatal demise. The infant and mother both demonstrated very high complement fixation titers of antibodies for cytomegalovirus, and the infant was found to have no atrioventricular node, thereby producing the heart block. The patient
was a 20-year-old white female, gravide 3, para prenatal course was uncomplicated until 28 weeks. At that time, a fetal heart rate of 50-60 bpm was noted and confirmed by a Doppler ultrasonic instrument and abdominal electrocardiogram (ECG) (Fig. 1). Ultrasound examination at 36 weeks revealed a fetus, normal in overall appearance, with biparietal diameter appropriate for gestational age. At 39weeks gestation, the patient began spontaneous labor and delivered a female infant of normal appearance, weighing 2,025 gm, with Apgar scores of 8 and 8. The fetus demonstrated a persistent heart rate of 60 bpm during labor (Fig. 2), and the newborn infant demonstrated complete heart block on ECG (Fig. 3). The infant did well for 36 hours. She then developed tachypnea and poor color. Blood gases from the arms were still normal. Several hours later, the abdomen became distended and the infant passed a bloody stool. At this time, umbilical artery catheterization revealed hypoxemia with persistently normal oxygenation in the arms, signifying persistent fetal circulation. The infant developed septic shock and was treated with antibiotics, steroids, and a pacemaker implant. However, the necrotizing enterocolitis worsened, with perforation requiring a partial colectomy; the infant died at 4 days of age. Viral antibody studies were reported after the infant’s death with a cytomegalovirus titer > 1 : 512. A maternal sample was then examined and found to have a cytomegalovirus titer of 1 : 16, 384. Autopsy revealed a patent ductus arteriosis, an anomalous origin of the right subclavian artery, acute nectotizing enterocolitis, and an absence of the atrioventricular node with microscopic calcium deposits near the His bundle which was normal. 2, whose
Fetal cardiac arrhythmias are uncommon during labor but are rarely diagnosed prior to labor. Also, few of the arrhythmias seen during labor will persist after delivery. This case demonstrates a severe arrhythmia with bradycardia making the distinction of fetal and maternal heart rates difficult. It is, of course, valuable for the pediatrician to be aware of any arrhythmia detected prior to delivery so that the newborn infant can be monitored for cardiac abnormalities.
968
Communications
in brief
April 1, 1980 J. Obstet. Gynecol.
Am.
Fig. 1. Abdominal ECG heart rate is 90 bpm.
with
Fig. ‘2. Fetal
Fig. 3. ECG of newborn infant ventricular rate of 50 bpm.
fetal
heart
and
maternal
signals:
fetal
heart
tracing
in labor
with
fetal electrode.
rate
demonstrating
The association of cytomegalovirus and cardiac malformations is anecdotal at this time, with no causeand-effect relationship yet proven. The interesting presence of calcium deposits near the location of the missing atrioventricular node may be significant, analagous to the glial reactions with calcification seen in central nervolls system cytomegalovirus involvement.
complete
heart
block
rate
with
is 60 bpm,
and
maternal
atria1 rate of 130 bpm
and
REFERENCES 1. Overall, J. C.: Intrauterine virus infections and congenital heart disease, Am. Heart J. 84:823, 1972. 2. Harris, R. E.: Viral teratogenesis: A review with experimental and clinical perspectives, AM. J. OBSTET. GYNECOL. 119:996, 1974.
136 7
Communications
the young and healthy population represented by IUD users, the also well-established association of bleeding and genital cancer is frequently forgotten. Genital malignancy has rarely been reported in association with the use of an IUD.’ A recent technical bulletin of the American College of Obstetricians and Gynecologists does not specifically mention this possibility while discussing abnormal bleeding with IUDs.’ In the first case, a 43-year-old woman was sent home twice with reassurance that her bleeding was secondary to the IUD. If not for the pathologic examination of the IUD, the diagnosis of malignancy would have been even further delayed. In the second case, this 24-year-old woman had an IUD inserted with a cervical lesion present. The clinical acumen of a senior attending physician was necessary to obtain the diagnosis. In addition to the mandatory Papanicolaou smear, we feel that the key to the diagnosis of a genital malignancy in IUD users is a high index of suspicion and a routine pathologic processing of the tissue attached to the IUD, which we have found to be almost always present. With these safeguards, early diagnosis of malignancy is greatly facilitated. REFERENCES
Harrison, R. F.: Adenocarcinoma of the uterine body following use of intrauterine contraceptive device, Ir. J. Med. Sci. 140:407, 1971. 2. The intrauterine device, ACOG Technical Bulletin, No. 40, June, 1976. 1.
Fetal heart block caused by cytomegalovirus P. E. LEWIS
II,
COMMANDER
(MC)
USN
R. C. CEFALO, CAPTAIN
(MC)
USN
A. L. ZARITSKY, LIEUTENANT
National CONGENITAL
Naval
(MC)
Medical HEART
occurs in approximately
USNR
Center,
Bethesda,
Maryland
of clinical significance five cases per 1,000 live births.
DISEASE
Presented at the Armed Forces District Meeting of the American College of Obstetricians and Gynecologists, Washington, D. C., October, 1978. The opinions or assertions contained herein are those of the authors and are not to be construed as official or reflecting the views of the Navy Department or of the Naval Service at large. Reprint requests: Commander P. E. Lewis II (MC) USN, Naval Regional Medical Center, Obstetrics and Gynecology Service, Portsmouth, Virginia 23708.
in brief
967
In most of these cases, no specific etiology can be determined. Viral infections during gestation have been associated with congenital heart disease in cases of rubella, Coxsackie B, and mumps viruses. A causeand-effect relationship appears valid for the rubella virus but is unproven for other viruses.’ Cytomegalovirus has been proven to cause congenital defects, including microcephaly, hydrocephaly, microphthalmia, cerebral calcification, and hepatosplenomegaly. Only infrequently have cardiovascular anomalies been associated with cytomegalovirus.’ In this report, congenital heart block was diagnosed at 28-weeks gestation with persistence after delivery at 39 weeks, and subsequent neonatal demise. The infant and mother both demonstrated very high complement fixation titers of antibodies for cytomegalovirus, and the infant was found to have no atrioventricular node, thereby producing the heart block. The patient
was a 20-year-old white female, gravide 3, para prenatal course was uncomplicated until 28 weeks. At that time, a fetal heart rate of 50-60 bpm was noted and confirmed by a Doppler ultrasonic instrument and abdominal electrocardiogram (ECG) (Fig. 1). Ultrasound examination at 36 weeks revealed a fetus, normal in overall appearance, with biparietal diameter appropriate for gestational age. At 39weeks gestation, the patient began spontaneous labor and delivered a female infant of normal appearance, weighing 2,025 gm, with Apgar scores of 8 and 8. The fetus demonstrated a persistent heart rate of 60 bpm during labor (Fig. 2), and the newborn infant demonstrated complete heart block on ECG (Fig. 3). The infant did well for 36 hours. She then developed tachypnea and poor color. Blood gases from the arms were still normal. Several hours later, the abdomen became distended and the infant passed a bloody stool. At this time, umbilical artery catheterization revealed hypoxemia with persistently normal oxygenation in the arms, signifying persistent fetal circulation. The infant developed septic shock and was treated with antibiotics, steroids, and a pacemaker implant. However, the necrotizing enterocolitis worsened, with perforation requiring a partial colectomy; the infant died at 4 days of age. Viral antibody studies were reported after the infant’s death with a cytomegalovirus titer > 1 : 512. A maternal sample was then examined and found to have a cytomegalovirus titer of 1 : 16, 384. Autopsy revealed a patent ductus arteriosis, an anomalous origin of the right subclavian artery, acute nectotizing enterocolitis, and an absence of the atrioventricular node with microscopic calcium deposits near the His bundle which was normal. 2, whose
Fetal cardiac arrhythmias are uncommon during labor but are rarely diagnosed prior to labor. Also, few of the arrhythmias seen during labor will persist after delivery. This case demonstrates a severe arrhythmia with bradycardia making the distinction of fetal and maternal heart rates difficult. It is, of course, valuable for the pediatrician to be aware of any arrhythmia detected prior to delivery so that the newborn infant can be monitored for cardiac abnormalities.
968
Communications
in brief
April 1, 1980 J. Obstet. Gynecol.
Am.
Fig. 1. Abdominal ECG heart rate is 90 bpm.
with
Fig. ‘2. Fetal
Fig. 3. ECG of newborn infant ventricular rate of 50 bpm.
fetal
heart
and
maternal
signals:
fetal
heart
tracing
in labor
with
fetal electrode.
rate
demonstrating
The association of cytomegalovirus and cardiac malformations is anecdotal at this time, with no causeand-effect relationship yet proven. The interesting presence of calcium deposits near the location of the missing atrioventricular node may be significant, analagous to the glial reactions with calcification seen in central nervolls system cytomegalovirus involvement.
complete
heart
block
rate
with
is 60 bpm,
and
maternal
atria1 rate of 130 bpm
and
REFERENCES 1. Overall, J. C.: Intrauterine virus infections and congenital heart disease, Am. Heart J. 84:823, 1972. 2. Harris, R. E.: Viral teratogenesis: A review with experimental and clinical perspectives, AM. J. OBSTET. GYNECOL. 119:996, 1974.