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The natural course of early intrauterine urethral obstruction
Volume 147 Number cf
Communications in brief
465
necrosis. Placental membranes and umbilical cord were also normal. Transmission electron microscopy of placental tissue demonstrated normal morphology. Villi contained mature trophoblasts and normal Hofbauer cells. Capillaries were lined by slender endothelial cells with no blebbing of the plasma membrane or cytoplasmic swelling or degeneration (Fig. 2). There was a normal basal lamina. Examination of larger placental vessels was similarly normal with no evidence of inflammation, necrosis, or deposition. Based on our experience and previous reports, the patient with Takayasu's arteritis may be reassured that, with proper rest, nutrition, and surveillance, she has an excellent chance of uncomplicated pregnancy and a healthy baby. Despite this reassurance, the obstetrician should be alert for hypertension, congestive heart failure, and deteriorating renal function during pregnancy and, because of compromised arterial compliance, must especially attend to fluid balance in the perinatal period. The absence of placental pathology. as reported here, is consistent with the documented pregnancy outcomes.
REFERENCES I. Ayers. M.A.: Takayasu syndrome and pregnancy: A tenyear follow-up, AM. j. 0BSTET. GYNECOL. 120:562, 1974. 2. Hauth, ]. C .. Cunningham, F. G., and Young, B. K.: Takayasu's syndrome in pregnancy, Obstet. Gynecol. 50: 373, 1977.
The natural course of early intrauterine urethral obstruction Marijke J. Korenromp, Marita J. P. Stassen, M.D., Ingrid van Ertbruggen, M.D., and Rita Kriek, M.D. Department of Obstetrics and Gynecology, University Hospital, and Wilhelmina Children's Hospital, Utrecht, The Netherlands
At present, stenosis of the urethra is one of the congenital defects for which intrauterine intervention can be considered. However, the degree and the time of onset of the obstruction vary widely, and the optimal time of intervention is currently not known. In this paper we describe a fetus in which a severe obstruction of the urethra was diagnosed at 17 weeks of gestation. Subsequently we were able to monitor the pregnancy sonographically until birth at 29 weeks without interference. In our opinion the natural course of the disease reveals some clues as to the optimal time of intervention. Because of a raised serum a-fetoprotein (AFP) level, a sonographic examination was performed in a 24-year-old Reprint requests: Marijke ]. Korenromp, Department of Obstetrics and Gynecology, University Hospital, Catharijnesingel 101, Utrecht, The Netherlands.
Fig. I. Scan at I 8 weeks of gestation showing a distended bladder and bilateral hydronephrosis.
primigravid woman at I 7 and I 8 weeks of gestation. A distended fetal bladder and bilateral hydronephrosis (Fig. 1) were found, and no other defects associated with raised AFP levels could be detected. At 185 /7 weeks an attempt to aspirate amniotic fluid was unsuccessful because by that time a severe oligohydramnios had developed, apparently within 5 days' time. At that moment the presence of a severe urethral obstruction could be assumed. Since the placenta was located on the anterior wall of the uterus, intrauterine insertion of a suprapubic indwelling catheter seemed impossible. The patient wished to continue her pregnancy. The subsequent weekly scans showed a remarkably moderate increase of bladder and ureter distention. However, both the bilateral hydronephrosis and the extreme oligohydramnios continued to exist. At 28 weeks the hydronephrosis suddenly disappeared and the bladder distention became less pronounced. Spontaneous labor ensued 6 days later, and the patient was delivered of a I, 145 gm male infant with the typical deformities of Potter's syndrome: low-set ears, asymmetric chest, and limb contractions. Neither the kidneys nor the bladder was palpable. Immediately after birth respiratory problems began and rapidly worsened. Despite artificial venti-
466
Communications in brief
October I 5. 1'lS:l
Am .. J. Obstct. Gvnewl.
hydronephrosis, and oligohydramnios. The urinarY tract was successfully decompressed and the pregnancv proceeded without complications. The child was born at 35 weeks but died soon after birth because of lung hypoplasia. At autopsy the urethra was completely occluded by posterior urethral valves. The kidneys showed Potter type IV cystic dysplasia. Apparently, at the time of the fetal surgical procedure (21 weeks), the renal damage was already too advanced. Harrison and associates believe that the development of oligoh\·dramnios is a reliable indicator of severe renal impairment. The sequence of events described in our patient could support the suggestion of Harrison and associates. At 185 /7 weeks sudden oligohydramnios occurred, and from that moment on the bladder distention and hydronephrosis were remarkably moderate, reflecting, in our opinion, progressing renal damage. It appears that in this case intrauterine intervention might have been useful before the occurrence of oligohydramnios, at 18 weeks at the latest. It is obvious that intrauterine surgery at such an early gestational stage will raise many still unresolved technical and ethical questions. We wish to thank the Institute of Pathology of the State Cniversitv of Utrecht.
Fig. 2. Autopsy specimen of tVOgenital tract.
lation, the infant died after 20 hours of life. Catheterization of the urethra revealed a complete obstruction at 3 em from the meatus. Autopsy was performed. The lungs showed moderate hyaline membrane disease and interstitial emphysema but no hypoplasia at routine microscopic examination. The urethra was completely obstructed by prostatic urethral valves; the bladder was hypertrophic, and the ureters were dilated. The kidneys showed severe medullary dysplasia. and the cortex was extremely hypoplastic (Fig. 2). Subcapsular cysts were clearly present. Osathanondh and Potter' classified this cystic dysplasia, which is caused by urethral obstruction, as type IV. Beck 2 has shown in fetal lambs that urethral obstruction produced by ligation in the last half of gestation produces only simple hydronephrotic kidneys. However, ligation in the first half of gestation resulted in dysplasia and failure of formation of the nephron. Elevated pressure in the developing nephron system apparently interferes with normal cellular proliferation and differentiation. Harrison and associatesa performed a bilateral ureterostomy in a 21-week-old fetus with urethral stenosis,
REFERENCES I. Osathanondh. V.. and Potter. E.: Pathogenesis of polycvstic kidneys. Type 4 due to urethral obstruction, Arch. Pathol. 77:502, 1964. 2. Beck, A. D.: The effect of intrauterine urinary obstruction upon the development of the fetal kidnev, J. Urol. 105:784, 1971. :>. Harrison, M. R., Golbus, M. S.. Fillv, R. A.. Callen, P. W.. Katz. M.. De Lorimer. A. A., Rozen: M., and Jones, A. R.: Fetal surgery for congenital hydronephrosis. N. Engl. .J. Med. 306:591. 1982.
Serum tobramycin levels in puerperal women Jorge D. Blanco, M.D., Ronald S. Gibbs, M.D., Patrick Duff, M.D., and Yolanda S. Castaneda, R.N. Department of Obstetrics and G.vnecology, The Univenity of Texas Health Science Center at San Antonio, San Antonio. Texas
Because of the excellent activity of aminoglycosides against gram-negative aerobic bacilli. they are often used, in conjunction with penicillin or dindamycin, to treat postpartum infections. 1 Use of aminoglycosides, This study was approved by the Institutional Review Board of The University of Texas Health Science Center at San Antonio. Reprint requests: Jorge D. Blanco, M.D., Department of Obstetrics and Gynecology, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr., San Antonio. Texas 78284.
Communications in brief
465
necrosis. Placental membranes and umbilical cord were also normal. Transmission electron microscopy of placental tissue demonstrated normal morphology. Villi contained mature trophoblasts and normal Hofbauer cells. Capillaries were lined by slender endothelial cells with no blebbing of the plasma membrane or cytoplasmic swelling or degeneration (Fig. 2). There was a normal basal lamina. Examination of larger placental vessels was similarly normal with no evidence of inflammation, necrosis, or deposition. Based on our experience and previous reports, the patient with Takayasu's arteritis may be reassured that, with proper rest, nutrition, and surveillance, she has an excellent chance of uncomplicated pregnancy and a healthy baby. Despite this reassurance, the obstetrician should be alert for hypertension, congestive heart failure, and deteriorating renal function during pregnancy and, because of compromised arterial compliance, must especially attend to fluid balance in the perinatal period. The absence of placental pathology. as reported here, is consistent with the documented pregnancy outcomes.
REFERENCES I. Ayers. M.A.: Takayasu syndrome and pregnancy: A tenyear follow-up, AM. j. 0BSTET. GYNECOL. 120:562, 1974. 2. Hauth, ]. C .. Cunningham, F. G., and Young, B. K.: Takayasu's syndrome in pregnancy, Obstet. Gynecol. 50: 373, 1977.
The natural course of early intrauterine urethral obstruction Marijke J. Korenromp, Marita J. P. Stassen, M.D., Ingrid van Ertbruggen, M.D., and Rita Kriek, M.D. Department of Obstetrics and Gynecology, University Hospital, and Wilhelmina Children's Hospital, Utrecht, The Netherlands
At present, stenosis of the urethra is one of the congenital defects for which intrauterine intervention can be considered. However, the degree and the time of onset of the obstruction vary widely, and the optimal time of intervention is currently not known. In this paper we describe a fetus in which a severe obstruction of the urethra was diagnosed at 17 weeks of gestation. Subsequently we were able to monitor the pregnancy sonographically until birth at 29 weeks without interference. In our opinion the natural course of the disease reveals some clues as to the optimal time of intervention. Because of a raised serum a-fetoprotein (AFP) level, a sonographic examination was performed in a 24-year-old Reprint requests: Marijke ]. Korenromp, Department of Obstetrics and Gynecology, University Hospital, Catharijnesingel 101, Utrecht, The Netherlands.
Fig. I. Scan at I 8 weeks of gestation showing a distended bladder and bilateral hydronephrosis.
primigravid woman at I 7 and I 8 weeks of gestation. A distended fetal bladder and bilateral hydronephrosis (Fig. 1) were found, and no other defects associated with raised AFP levels could be detected. At 185 /7 weeks an attempt to aspirate amniotic fluid was unsuccessful because by that time a severe oligohydramnios had developed, apparently within 5 days' time. At that moment the presence of a severe urethral obstruction could be assumed. Since the placenta was located on the anterior wall of the uterus, intrauterine insertion of a suprapubic indwelling catheter seemed impossible. The patient wished to continue her pregnancy. The subsequent weekly scans showed a remarkably moderate increase of bladder and ureter distention. However, both the bilateral hydronephrosis and the extreme oligohydramnios continued to exist. At 28 weeks the hydronephrosis suddenly disappeared and the bladder distention became less pronounced. Spontaneous labor ensued 6 days later, and the patient was delivered of a I, 145 gm male infant with the typical deformities of Potter's syndrome: low-set ears, asymmetric chest, and limb contractions. Neither the kidneys nor the bladder was palpable. Immediately after birth respiratory problems began and rapidly worsened. Despite artificial venti-
466
Communications in brief
October I 5. 1'lS:l
Am .. J. Obstct. Gvnewl.
hydronephrosis, and oligohydramnios. The urinarY tract was successfully decompressed and the pregnancv proceeded without complications. The child was born at 35 weeks but died soon after birth because of lung hypoplasia. At autopsy the urethra was completely occluded by posterior urethral valves. The kidneys showed Potter type IV cystic dysplasia. Apparently, at the time of the fetal surgical procedure (21 weeks), the renal damage was already too advanced. Harrison and associates believe that the development of oligoh\·dramnios is a reliable indicator of severe renal impairment. The sequence of events described in our patient could support the suggestion of Harrison and associates. At 185 /7 weeks sudden oligohydramnios occurred, and from that moment on the bladder distention and hydronephrosis were remarkably moderate, reflecting, in our opinion, progressing renal damage. It appears that in this case intrauterine intervention might have been useful before the occurrence of oligohydramnios, at 18 weeks at the latest. It is obvious that intrauterine surgery at such an early gestational stage will raise many still unresolved technical and ethical questions. We wish to thank the Institute of Pathology of the State Cniversitv of Utrecht.
Fig. 2. Autopsy specimen of tVOgenital tract.
lation, the infant died after 20 hours of life. Catheterization of the urethra revealed a complete obstruction at 3 em from the meatus. Autopsy was performed. The lungs showed moderate hyaline membrane disease and interstitial emphysema but no hypoplasia at routine microscopic examination. The urethra was completely obstructed by prostatic urethral valves; the bladder was hypertrophic, and the ureters were dilated. The kidneys showed severe medullary dysplasia. and the cortex was extremely hypoplastic (Fig. 2). Subcapsular cysts were clearly present. Osathanondh and Potter' classified this cystic dysplasia, which is caused by urethral obstruction, as type IV. Beck 2 has shown in fetal lambs that urethral obstruction produced by ligation in the last half of gestation produces only simple hydronephrotic kidneys. However, ligation in the first half of gestation resulted in dysplasia and failure of formation of the nephron. Elevated pressure in the developing nephron system apparently interferes with normal cellular proliferation and differentiation. Harrison and associatesa performed a bilateral ureterostomy in a 21-week-old fetus with urethral stenosis,
REFERENCES I. Osathanondh. V.. and Potter. E.: Pathogenesis of polycvstic kidneys. Type 4 due to urethral obstruction, Arch. Pathol. 77:502, 1964. 2. Beck, A. D.: The effect of intrauterine urinary obstruction upon the development of the fetal kidnev, J. Urol. 105:784, 1971. :>. Harrison, M. R., Golbus, M. S.. Fillv, R. A.. Callen, P. W.. Katz. M.. De Lorimer. A. A., Rozen: M., and Jones, A. R.: Fetal surgery for congenital hydronephrosis. N. Engl. .J. Med. 306:591. 1982.
Serum tobramycin levels in puerperal women Jorge D. Blanco, M.D., Ronald S. Gibbs, M.D., Patrick Duff, M.D., and Yolanda S. Castaneda, R.N. Department of Obstetrics and G.vnecology, The Univenity of Texas Health Science Center at San Antonio, San Antonio. Texas
Because of the excellent activity of aminoglycosides against gram-negative aerobic bacilli. they are often used, in conjunction with penicillin or dindamycin, to treat postpartum infections. 1 Use of aminoglycosides, This study was approved by the Institutional Review Board of The University of Texas Health Science Center at San Antonio. Reprint requests: Jorge D. Blanco, M.D., Department of Obstetrics and Gynecology, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr., San Antonio. Texas 78284.