Results of chromosomal analysis in fetuses with cardiac anomalies as diagnosed by first- and early second-trimester echocardiography

Chromosomal analyses were performed in 36 fetuses with cardiac anomalies diagnosed by echocardiography at 11 + 1 to 15 + 6 weeks of gestation. Karyotyping was successful in 35 cases and 17 (48.6%) had anomalies, including five with Turner's syndrome, seven with trisomy 18, four with trisomy 21 and one with triploidy. The commonest cardiac anomaly observed in trisomy 21 was a complete atrioventricular canal; in trisomy 18 was ventricular septal defect; in Turner's syndrome was a hypoplastic aortic arch in combination with hypoplasia of the left ventricle and left ventricular outflow tract; and in the case of triploidy was a ventricular septal defect. These findings confirm the opinion that, in fetuses with chromosomal anomalies, there is a high incidence of cardiac defects. Furthermore, there is a distinct pattern of cardiac defects associated with each chromosomal anomaly.

Early diagnosis of fetal congenital heart disease by transvaginal echocardiography

Fetal echocardiography was performed using a high-frequency vaginal ultrasound probe in 114 singleton pregnancies between 11 and 16 weeks of gestation. The four-chamber view with both atria, atrioventricular valves and ventricles as well as the origin and double-crossing of aorta and pulmonary trunk could always be demonstrated from the 13th week onwards. In 12 of 13 cases, cardiac malformations were diagnosed in the first trimester. Only in one case was transabdominal echocardiography necessary at 20 weeks to make the diagnosis. In several cases, however, additional malformations were overlooked, in particular anomalies of the great arteries, such as coarctation of the aorta. Therefore, the accuracy of second-trimester transabdominal echocardiography is markedly higher. Because of the lower diagnostic accuracy, the high costs of equipment and the high training demanded of the examiner, first-trimester transvaginal echocardiography should be restricted to the high-risk fetus, i.e.: (1) Cases with other fetal anomalies very often associated with cardiac defects, such as nuchal edema and hygroma, non-immune hydrops, omphalocele, situs, inversus, or persisting arrythmia; (2) High-risk families with one or more first-degree relatives with cardiac defects are either inherited by Mendelian rules alone, or as part of a rare syndrome; and (3) In pregestational diabetes of the mother.Thus, many severe cardiac defects can be detected or excluded in the first trimester, reducing maternal anxiety. In these high-risk cases, second-trimester echocardiography using the transabdominal route should always be performed because of its distinctly higher diagnostic accuracy.

Steinfeld syndrome: report of a second family and further delineation of a rare autosomal dominant disorder

We report on a fetus with alobar holoprosencephaly, microphthalmia, midline cleft lip and palate, absent nose, dysplastic ears, radial defects, pentalogy of Fallot, unilateral renal aplasia, absent gallbladder, vertebral anomalies, and absence of ribs. The father had a cleft palate, bilateral colobomas of the iris and retina, a bifid uvula, vertebral anomalies, and unilateral congenital hearing loss. His sister had a cleft lip. On the basis of this family and the family reported by Steinfeld [1982], this malformation syndrome can be defined as a rare autosomal dominant syndrome whose main component manifestations are holoprosencephaly, predominantly radial limb deficiency, heart defects, kidney malformations, absence of gallbladder, and vertebral anomalies.

Prenatal diagnosis of atrioventricular canal malformations with up-to-date echocardiographic technology: report of 14 cases

Fourteen fetuses with atrioventricular canal malformations were examined by two-dimensional echocardiography, pulsed-wave Doppler echocardiography, and color Doppler flow mapping. Eleven fetuses had complete and three fetuses had partial atrioventricular canal malformations. Nonimmune hydrops fetalis was associated with six cases, and fetal arrhythmia was seen in three cases. With two-dimensional echocardiography, the atrioventricular canal malformations could be diagnosed accurately. The inclusion of color Doppler flow mapping, however, provided additional hemodynamic information that was important from the prognostic point of view. Incompetence of atrioventricular valves could be demonstrated in 10 of 14 cases by Doppler echocardiography. In nine cases, detailed Doppler echocardiographic evaluation of the regurgitation jet was possible. The proportion of systolic time during which atrioventricular valve insufficiency was demonstrated was related to the occurrence of nonimmune hydrops fetalis. When insufficiency of atrioventricular valves was associated with hydrops (four cases), a pansystolic insufficiency was always present. In cases without hydrops (five), regurgitation was confined to early systole. Thus a reliable method for semiquantitative evaluation of the degree of insufficiency seems to have been found. Moreover, an association appeared to exist between the occurrence of hydrops fetalis and the proportion of atrial area that was taken up by regurgitant jet area, as determined by planimetry in the four-chamber view. Prenatal diagnosis was confirmed by autopsy or neonatal cardiac evaluation. Only one neonate survived in our series. Two were stillborn, four died during the neonatal period, two died during infancy, and pregnancy was electively terminated prematurely in five cases. Eight fetuses were found to have a karyotypic abnormality.

Flow analysis in the pulmonary trunc in fetuses with tetralogy of Fallot by colour Doppler flow mapping; two case reports

Prenatal diagnosis of tetralogy of Fallot by two-dimensional echocardiography, which is based on demonstration of a ventricular septal defect and a large overriding aorta, is difficult. In the majority of cases the main pulmonary artery is small. In utero, there is no pathologically increased degree of the physiological right-ventricular hypertrophy. Colour Doppler flow mapping of reverse flow from the descending aorta via the ductus arteriosus into the main pulmonary artery is easily demonstrated, and provides an indirect sign of severe right-ventricular outlet obstruction. The technique also differentiates between pulmonary stenosis and atresia; the stenotic jet, even small, is identified by demonstration of high velocities and turbulences in the main pulmonary artery.

[Primary and metastatic liver tumors--evaluation of tumor regression and response with regional cytostatic drug therapy by sonography and fine needle puncture histology]

Primary and metastatic hepatic tumours--evaluation of tumour regression or response under regional cytostasis with sonography and fine needle puncture histology. The results obtained through the use of regional liver perfusion with a 5-FU-BCNU application on non-resectable hepatic metastases of colorectal tumours following primary curative removal of the primary tumour and primary hepatocellular carcinomas display comparable results to those specified in the literature after the use of 5-FUDR. The effectivity of the cytostasis regime is checked using histological criteria. The ultrasonically guided fine needle puncture can prove the success of the cytostasis regime on the basis of cytomorphologic criteria more reliably than has been the case up to now. Patients displaying histological signs of tumour regression have a significantly longer survival time than those displaying no signs of regression (12 +/- 9.2 vs 4.5 +/- 2.2 months; p less than 0.05).

First-trimester diagnosis of fetal congenital heart disease by transvaginal two-dimensional and Doppler echocardiography

Until recently, prenatal diagnosis of fetal cardiac malformations was restricted to the second and third trimesters. With the advent of high-frequency transvaginal probes, earlier detection of such malformations is possible. We present a case of nonimmune hydrops fetalis with complete atrioventricular canal defect, insufficiency of atrioventricular valves, and complete heart block at 11 weeks' gestation diagnosed by transvaginal two-dimensional and Doppler echocardiography.

Fetal complete heart block: antenatal diagnosis, significance and management

Complete heart block was diagnosed prenatally in 21 fetuses. Associated structural cardiac defects were present in 18 fetuses, in particular complete atrioventricular canal with atrial isomerism (5 cases), and 'corrected' transposition of the great arteries (4 cases). Maternal systemic lupus erythematosus was proved in only one case. In 11 fetuses, intra-uterine congestive heart failure with the signs of non-immune hydrops fetalis occurred. In all 11 fetuses, the hydrops was associated with a cardiac defect, in particular complete atrioventricular canal with atrial isomerism in 5 cases. A review of the literature confirms that only the association of complete heart block and cardiac malformation can cause intra-uterine congestive heart failure, whereas in the case of fetal complete heart block without cardiac malformation or with prenatally hemodynamically insignificant cardiac malformation, congestive heart failure is rare. Only 30% of newborns with complete heart block have associated cardiac malformations. In our series, however, 86% of the fetuses with complete heart block had cardiac malformations. The most important reason for this percentage discrepancy is that almost all fetuses with associated severe cardiac defects, in particular atrioventricular canal defects, develop heart failure which frequently results in prenatal death. Thus, fetal deaths are not included in pediatric statistics. Nevertheless, fetuses with isolated complete heart block generally do not develop heart failure and in almost all of the cases are born alive.

[Prenatal diagnosis of severe tricuspid valve insufficiency in Ebstein anomaly with pulmonary valve atresia by 2-dimensional color coded Doppler echocardiography]

By the application of all methods of fetal echocardiography the prenatal diagnosis and a prognostically correct assessment was reached in a severe case of Ebstein's anomaly of tricuspid valve associated with pulmonary atresia, severe tricuspid regurgitation, and a hypoplastic main pulmonary artery. It is demonstrated that only the application of two-dimensional color-coded Doppler-echocardiography followed by a spectral-Doppler-echocardiography can result in an accurate evaluation of hemodynamical alterations and thus in the prognostic assessment in the reported case.

[Non-immunologically-induced hydrops fetalis in complete atrioventricular block of the fetus. A summary of 11 prenatally diagnosed cases]

In 11 of 21 fetuses with prenatally diagnosed complete heart block, congestive heart failure with signs of non-immune hydrops fetalis was seen. In all 11 fetuses, cardiac malformations were present: complete atrioventricular canal with levocardia, situs inversus viscerum, and polysplenia: 5 cases; tricuspid atresia with situs inversus viscerum, endocardial fibroelastosis, common atrium with aortic valve atresia, hypoplastic left heart, atrial septal defect of secundum type: one case each. All these cardiac malformations can also cause intrauterine heart failure without heart block except hypoplastic left heart and atrial septal defect. A review of the literature confirms, that only the association between complete heart block and cardiac malformation--in particular AV-canal and endocardial fibroelastosis--can cause an intrauterine congestive heart failure, whereas in the case of fetal complete heart block without cardiac malformation or with prenatally hemodynamically insignificant cardiac malformations--in particular "corrected" transposition of great arteries--a congestive heart failure is rare.

Gliomatosis peritonei with endometriosis externa

A case of gliomatosis peritonei developed 9 years after the removal of an immature ovarian teratoma is reported. An unique association of gliomatosis with endometriosis externa was found without the usual symptoms of endometriosis. The prognosis of gliomatosis is generally excellent and depends on the histological grade of the primary tumor and on the presence of organ metastasis or immature tumor elements in the implants. Pathogenetical aspects of both lesions are discussed briefly.

Listeriosis: a cause of non-immune hydrops fetalis

A case of prenatally diagnosed non-immune hydrops fetalis, that was later shown to be caused by listeriosis, is presented, and the clinical course, as well as the appropriate diagnostic and therapeutic procedures are described. We conclude, that listeriosis should be excluded, whenever a non-immune hydrops fetalis is associated with septicemia, influenza-like illness and fever of unknown origin.

[Retroperitoneal teratoma. A problem in pediatric urology]

We report about diagnosis and therapy of a retroperitoneal teratoma in a six years old boy. Further we discuss the histogenetical origin as well as the histological classification. Considering other localisations, teratomas of the retroperitoneum are relatively (4%) rare. Most teratomas are diagnosed at school-age either coincidently or because of a mass lesion. Size and localisation of the tumor do not give any information about its nature. Even with negative tumor markers (alpha1-fetoprotein, beta-HCG) the tumor should be considered malignant until histology proves the contrary. Due to these facts a careful en bloc extirpation and a thorough histological examination of the tumor are always necessary.

[Adrenal cortex carcinoma in childhood and adolescence]

The presented paper includes the medical records of two girls with adrenal cortical carcinomas on the one hand and the detailed analysis of a collected series of 150 equal cases in pediatric literature on the other hand. In our patients there were a primarily metastatic, non-functioning tumour and a locally invasive, hormone-secreting neoplasm respectively. The latter one produced a Cushing's syndrome with signs of virilization. In this case surgical removal was followed by postoperative irradiation and adjunctive cytostatic therapy with cyclophosphamide and adriamycin for one year. But tumour recurrence occurred within 6 months. A treatment with the antitumour agents aminogluthetimide and o,p' DDD was transiently effective. However drug-induced side effects necessitated the stop of this regimen after 5 months. The analysis of 150 case reports revealed a peak between 1 and 3 years of age, a striking prevalence of the female sex in all age groups, and a metastasizing rate of about 30% at the time of diagnosis. Regional structures, liver and lung were the main locations of metastatic lesions. The occurrence of second primary neoplasms and the association with a group of other conditions particularly congenital disorders have proved to be a remarkable feature of the disease. In primary adrenal cortical tumours the determination of the neoplasm's biological behaviour by morphologic criteria alone can often be very problematical. This fact is especially stressed.

Prenatal diagnosis of genetically determined early manifestation of autosomal dominant polycystic kidney disease?

A case of an unusually early manifestation of autosomal dominant polycystic kidney disease (ADPKD) is reported that was prenatally diagnosed by ultrasound. The ultrasonographic picture showed greatly enlarged kidneys and increased echogenicity that was indistinguishable from cases of autosomal recessive polycystic kidney disease or Meckel syndrome without further information. Because of two further cases of early manifestation of ADPKD within the family reported (brother and cousin), as well as several other "familial" cases reported in the literature, we postulate that genetic factors are involved (modifying alleles). When reported observations of "familial" cases of early manifestations of ADPKD are made, genetic counseling should be considered.

[The thyroid hormone system in mucoviscidosis]

Endocrine disorders do not represent primary manifestations in children with cystic fibrosis. Abnormal thyroid gland function is commonly observed in patients with chronic nonthyroidal illnesses. Serum concentrations of TSH, T4 and T3 were measured and a TRH-stimulation test (200 micrograms Relefact per kg body weight) was performed in 24 patients with CF 6 to 16 1/2 years of age. As compared to the controls, CF patients had increased basal TSH and lower T4 and T3 concentrations. Finally they exhibited higher TRH-stimulated TSH and decreased peripheral T4 and T3. There was no correlation to the nutritional status or the Shwachman scores. In all patients with CF albumin, TBG and TBPA were also normal. Our results indicate a subclinical hypothyroidism in CF. Routine therapy with thyroid hormones is neither necessary nor recommended.

[Familial adenomatosis coli--a precancerous condition]

The presented paper includes the medical records of five children with familial adenomatous polyposis coli on the one hand and the detailed description of the pathologic findings of the disease on the other hand. Particular emphasis is given to the morphologic criteria of the disorder predisposing the affected individuals to development of colorectal cancer at unusually early ages. In the current cases there was a so-called classical presentation of diffuse polyposis in the early and late childhood respectively. The diagnosis was established in supposedly unaffected siblings due to colonoscopy and radiologic procedures. Prophylactic total colectomy was performed in all proven cases. The association with extracolonic tumours has proved to be a remarkable feature of the disease. This fact is especially stressed.

[Endocrine pancreas function in mucoviscidosis]

Patients with cystic fibrosis of the pancreas show an incidence of diabetes mellitus tenfold higher than is found in the general pediatric population. Considering this fact glucagon and insulin responses to oral glucose and intravenous arginine were studied in 22 CF children and adolescents. Some investigated patients had suffered from the disease for ten years and more. On the one hand the results show that pancreatic alpha cell function is normal. The kinetics of endogenous glucagon release are unaltered. On the other hand the data reveal that there is only a defect in the beta cell function consisting in a delayed insulin release selective to glucose whereas responsiveness to other stimuli for example tolbutamide and arginine is undisturbed. Furthermore there is a diminution in insulin-output to oral glucose as well as to intravenous arginine. Yet in patients with normal oral glucose tolerance endogenous insulin secretion is significantly reduced. Their regular carbohydrate tolerance may be a function of the patient's ability to maintain increased receptor numbers in the face of hypoinsulinemia. Despite greater quantities of secreted hormone a degree of relative peripheral insulin insensitivity has developed in the presence of hyperglycemia. This may be a consequence of impaired affinity of the specific target cell receptors. The insulin secretion pattern is proven to be identical to that of chemical diabetes mellitus in adults. Quantitative diminution in arginine stimulated insulin-output has been found to be independent of the degree of carbohydrate intolerance.(ABSTRACT TRUNCATED AT 250 WORDS)

[Malignant pheochromocytoma in childhood and adolescence--clinical case and review of the literature]

In regard to the diagnostic and therapeutic dilemma concerning rare neoplasms in childhood, the presented paper includes the comprehensive description of a malignant pheochromocytoma in a 14-year-old girl on the one hand and the detailed analysis of a collected series of 21 equal cases in pediatric literature on the other hand. In our patient there was in particular a lack of hypertension in spite of proven hypercatecholaminemia, an initially good effect of the post-operative aggressive chemotherapy according to the neuroblastoma study NBL 79 (4b) resulting in a transient reduction of the pulmonary metastases, furthermore a diminuation of the total tumour mass induced by the last applied treatment with the radiopharmaceutical 131I-metaidiobenzylguanidine. The analysis of 21 case reports revealed a peak between 10 and 15 years of age, a striking prevalence of the female sex in all age groups, and a high frequency of metastases (75%) at the time of diagnosis. Two thirds of the primary tumours arose in extra-adrenal sites, about one third occurred in the adrenal gland. The regional lymph nodes, the bone system and the lungs were the main locations of metastatic lesions. The association with a group of other conditions, particularly hypoxemic congenital heart malformations has proved to be a remarkable feature, but not only in the malignant forms.(ABSTRACT TRUNCATED AT 250 WORDS)

[Cortical hyperostoses after long-term prostaglandin E2 therapy]

Cortical hyperostoses are found to be side effects after therapy in early infancy with prostaglandin E1 and E2. Correlation seems to exist between dosage and duration of therapy. Radiologically the lesions cannot be differentiated from Caffey's disease. Pathogenetic relationship of the two diseases is discussed; 62 cases of newborn children with ductal related vitium cordis, who were treated for a short time or for longer with prostaglandin E2 are demonstrated.

Wilms' tumor in the adolescent and adult

Two rare cases of adolescent and adult Wilms' tumors are reported. All pertinent clinical data are presented. Both patients have been treated by radical tumor nephrectomy, irradiation and polychemotherapy. Only 4 patients with such triple treatment have been reported in the literature. The adolescent girl experienced a complete remission, but the 59-year-old patient rapidly deteriorated and died 4 months postoperatively.

[Treatment of initial urinary tract infection in children with cotrifamole and cotrimoxazole. A double-blind study]

28 children with initial episodes of urinary tract infection were treated with cotrimoxazole or cotrifamole (dose ratio 3 : 2) for 14 days in a prospective randomized double blind trial. The two groups did not differ as regards clinical signs. The efficacy and cure rates of each regimen were similar. Laboratory studies (hemoglobin, WBC, liver, and renal function) showed no differences between both groups before and after therapy; an alteration of the laboratory values could not be observed during therapy. The number of children with X-ray abnormalities of kidneys and urinary tract was similar in both groups. During an observation time of up to 12 months after the first urinary tract infection no differences in the number of reinfections and relapses were observed. As a result of this study, we recommend cotrifamole in a lower dose (ratio 2 : 3) than cotrimoxazole for the treatment of urinary tract infection.