Uterine artery blood flow volume in pregnant women with an abnormal pulsatility index of the uterine arteries delivering normal or intrauterine growth restricted newborns

The aim of this study was to assess and compare uterine artery (UtA) blood flow volume in pregnant patients with an abnormal uterine Doppler pulsatility index (PI) who delivered fetuses with an appropriate weight for gestational age (AGA) or with intrauterine growth restricted (IUGR). We prospectively recruited singleton pregnancies with abnormal uterine arteries P.I. between 18 and 38 weeks of gestation regardless of estimated fetal weight (EFW). Vessel diameter and blood flow velocity were measured along the UtA upstream to the vessel bifurcation in both the right and left UtAs. Uterine blood flow volumes measured in these pregnancies were compared to historical Control-pregnancies. Forty-three patients delivered at term a normal weight newborn (AGA-pregnancies). Thirty patients delivered growth restricted newborns at 32 weeks (i.r. 29-36w) with a median weight of 1160 gr (i.r. 1000-2065 gr) (IUGR-pregnancies). At mid-gestation (18 + 0 - 25 + 6 weeks + days of gestation) a significantly lower uterine blood flow volume per unit weight was observed between the two study groups and compared to controls: 142 ml/min/kg in IUGR-pregnancies, 217 ml/min/kg in AGA-pregnancies and 538 ml/min/kg in Control-pregnancies. These striking differences in blood flow volume were already present at mid-gestation, at a time when EFW was still normal. In late gestation (27 + 0 - 37 + 6 weeks + days of gestation), pregnancies with an abnormal uterine P.I. showed persistently low UtA flow (<50% of controls) even when corrected for fetal weight: 81 ml/min/kg in IUGR-pregnancies, 105 ml/min/kg in AGA-pregnancies, and 193 ml/min/kg in Control-pregnancies; p < 0.0001. Our findings are consistent with other recent studies regarding the association between reduced uterine blood flow volume and fetal growth restriction. However, the study brings new insight into the finding of abnormal uterine P.I. in normally grown fetuses typically dismissed as "falsely abnormal" or "false positive" findings. Our study suggests that blood flow volume measurement may serve as a new tool to assess this group of patients and possibly those with ischemic placental diseases that may provide some basis for therapeutic interventions.

Prognostic markers of symptomatic congenital human cytomegalovirus infection in fetal blood

OBJECTIVE

To identify fetal cord blood prognostic markers of symptomatic congenital human cytomegalovirus infection (HCMV).

DESIGN

Retrospective observational study.

SETTING

Fetal medicine unit in Milan and Medical virology unit in Pavia, Italy.

POPULATION

HCMV-infected and -uninfected fetuses of mothers with primary HCMV infection during the period 1995-2009.

METHODS

Overall, 94 blood samples from as many fetuses of 93 pregnant women experiencing primary HCMV infection were examined for multiple immunological, haematological and biochemical markers as well as virological markers. Congenital HCMV infection was diagnosed by detection of virus in amniotic fluid, and symptomatic/asymptomatic infections were determined by ultrasound scans, nuclear magnetic resonance imaging, histopathology or clinical examination at birth. Blood sample markers were retrospectively compared in symptomatic and asymptomatic fetuses with congenital infection.

MAIN OUTCOME MEASURES

A statistical analysis was performed to determine the value of each parameter in predicting outcome.

RESULTS

Univariate analysis showed that most nonviral and viral markers were significantly different in symptomatic (n = 16) compared with asymptomatic (n = 31) fetuses. Receiver operator characteristics analysis indicated that, with reference to an established cutoff for each marker, the best nonviral factors for differentiation of symptomatic from asymptomatic congenital infection were β(2) -microglobulin and platelet count, and the best virological markers were immunoglobulin M antibody and DNAaemia. β(2) -Microglobulin alone or the combination of these four markers reached the optimal diagnostic efficacy.

CONCLUSIONS

The determination of multiple markers in fetal blood, following virus detection in amniotic fluid samples, is predictive of perinatal outcome in fetuses with HCMV infection.

Growth of fetal lean mass and fetal fat mass in gestational diabetes

OBJECTIVES

This study was carried out to investigate growth indicators of fetal lean mass and fat mass in the second half of the gestational period in pregnancies complicated by gestational diabetes mellitus (GDM) in comparison to normal control pregnancies.

METHODS

Forty-three control and 171 GDM pregnancies were followed longitudinally by ultrasound examinations, measuring both traditional biometric parameters and six non-traditional parameters for the evaluation of lean and fat mass. A mixed linear model derived from the log-Count function was used to model fetal growth and to make comparisons between groups. Factor analysis was used to evaluate the associations between gestational diabetes and fetal size and fetal fat/lean mass ratios.

RESULTS

A total of 506 scans were obtained in the 214 pregnancies, a mean of 2.4 scans per pregnancy (range 2-5). Maternal age, prepregnancy weight and body mass index were significantly higher in GDM pregnancies. Fetuses of GDM pregnancies showed greater growth, at the same gestational age, for each lean and fat non-traditional parameter, having a significantly greater amount of total tissue mass and a higher fat mass/lean mass ratio, independent of gestational age, in comparison to control pregnancies.

CONCLUSIONS

A non-invasive, repeatable evaluation of fetal body composition in utero could represent a useful method for the early detection of growth abnormalities and for direct estimation of the fetal metabolic status.

Terms, definitions and measurements to describe the sonographic features of the endometrium and intrauterine lesions: a consensus opinion from the International Endometrial Tumor Analysis (IETA) group

The IETA (International Endometrial Tumor Analysis group) statement is a consensus statement on terms, definitions and measurements that may be used to describe the sonographic features of the endometrium and uterine cavity on gray-scale sonography, color flow imaging and sonohysterography. The relationship between the ultrasound features described and the presence or absence of pathology is not known. However, the IETA terms and definitions may form the basis for prospective studies to predict the risk of different endometrial pathologies based on their ultrasound appearance.

Intravenous contrast ultrasound examination using contrast-tuned imaging (CnTI) and the contrast medium SonoVue for discrimination between benign and malignant adnexal masses with solid components

OBJECTIVE

To determine whether intravenous contrast ultrasound examination is superior to gray-scale or power Doppler ultrasound for discrimination between benign and malignant adnexal masses with complex ultrasound morphology.

METHODS

In an international multicenter study, 134 patients with an ovarian mass with solid components or a multilocular cyst with more than 10 cyst locules, underwent a standardized transvaginal ultrasound examination followed by contrast examination using the contrast-tuned imaging technique and intravenous injection of the contrast medium SonoVue(R). Time intensity curves were constructed, and peak intensity, area under the intensity curve, time to peak, sharpness and half wash-out time were calculated. The sensitivity and specificity with regard to malignancy were calculated and receiver-operating characteristics (ROC) curves were drawn for gray-scale, power Doppler and contrast variables and for pattern recognition (subjective assignment of a certainly benign, probably benign, uncertain or malignant diagnosis, using gray-scale and power Doppler ultrasound findings). The gold standard was the histological diagnosis of the surgically removed tumors.

RESULTS

After exclusions (surgical removal of the mass > 3 months after the ultrasound examination, technical problems), 72 adnexal masses with solid components were used in our statistical analyses. The values for peak contrast signal intensity and area under the contrast signal intensity curve in malignant tumors were significantly higher than those in borderline tumors and benign tumors, while those for the benign and borderline tumors were similar. The area under the ROC curve of the best contrast variable with regard to diagnosing borderline or invasive malignancy (0.84) was larger than that of the best gray-scale (0.75) and power Doppler ultrasound variable (0.79) but smaller than that of pattern recognition (0.93).

CONCLUSION

Findings on ultrasound contrast examination differed between benign and malignant tumors but there was a substantial overlap in contrast findings between benign and borderline tumors. It appears that ultrasound contrast examination is not superior to conventional ultrasound techniques, which also have difficulty in distinguishing between benign and borderline tumors, but can easily differentiate invasive malignancies from other tumors.

Blood flow volume of uterine arteries in human pregnancies determined using 3D and bi-dimensional imaging, angio-Doppler, and fluid-dynamic modeling

The primary aim of this pilot study was to study uterine artery (UtA) blood flow volume in uneventful human pregnancies delivered at term, at mid and late gestation by means of 3D and bi-dimensional ultrasound imaging with angio-Doppler combined with fluid-dynamic modeling. Secondary aims were to correlate flow volume to placental site and to UtA Pulsatility Index (PI). Women with singleton, low-risk pregnancies were examined at mid and late gestation. The structure and course of the uterine artery (UtA) was studied in each patient by means of 3D-angio-Doppler and included vessel diameter D, blood flow velocity and PI (measured along the UtA). Fetal weight estimation and placental insertion site were assessed by ultrasound. A robust fluid-dynamic modeling was applied to calculate absolute flow and flow per unit fetal weight. Mean UtA diameter and blood flow velocity increased significantly (p < 0.0001) from mid-gestation to late gestation from 2.6 mm and 67.5 cm/s, to 3.0 mm and 85.3 cm/s, respectively, yielding an increasing absolute flow troughout gestation. h coefficient, derived by fluid-dynamic modeling to calculate mean velocity, increased significantly from 0.52 at mid-gestation to 0.57 at late gestation. UtA blood flow volume ml/min/kg-fetal weight was significantly higher at mid-gestation than at late gestation (535 ml/min/kg vs 193 ml/min/kg; p < 0.0001). In cases with strictly lateral placentas the ipsilateral UtA accommodates at mid and late gestation 63% and 67% of the total UtA flow. In central placentas UtA flow was evenly distributed between the two vessels. An inverse correlation was observed between PI and blood flow volume ml/min/kg (Pearson's coefficient r = -0.54). Our work confirms the technological and methodological limitations in the measurement of uterine artery blood flow. However, Doppler measurements supported by three-dimensional angio imaging of the uterine vessel, high resolution imaging and diameter measurement, and a robust mathematical model of local circulation adds a genuine new area of investigation into human uterine circulation during pregnancy.

XPA and XRCC3 gene polymorphisms and survival in esophageal cancer patients receiving neoadjuvant radiochemotherapy with cisplatin (CDDP), docetaxel (DTX), and 5-fluorouracil (FU)

e14571

Background: The aim of the study was to evaluate if genetic polymorphism of DNA repair genes may predict pathological response and survival in patients affected by locally advanced esophageal cancer, treated with a neoadjuvant schedule including weekly DTX (35 mg/mq) and CDDP (25mg/mq), protracted venous infusion of FU (150 mg/mq/die) and concomitant radiotherapy for 8 weeks followed by surgery. Methods: Fifty-seven patients were enrolled, aged 60±7 years old. Median follow-up was 27 months. Genomic DNA was extracted from peripheral blood lymphocytes and XPA, XPD, XRCC1, ERCC1 and XRCC3 were genotyped through RFLP analysis. Associations between gene polymorphisms and pathological response and survival were analysed through Chi square test and Log rank test respectively. Results: Thirty-two patients presented complete remission (pCR) and 10 patients microfocal residual disease (pMRD); the remaining 15 patients were considered stable or non-responders (pS-NR). The event free(EFS) and overall (OS) median survival times have not yet reached; significantly better 3-year survival rates were observed after pCR than in case of pMRD and pS-NR (EFS: 87% vs 42.8%, p=0.0004; OS: 86% vs 56%, p=0.02, respectively). No association was found between pathological response or survival with XRCC1, ERCC1 and XPD polymorphisms. On the contrary, the XPA 23AA genotype showed an increased risk of recurrence (HR=3.5; 95% CI 1.3 to 43.7, p=0.02) and death (HR=4.4, 95% CI 1.9 to 78.2, p=0.009); there was a trend for reduced risk of negative pathological response with decreasing number of allele 23A : MRD and S-NR were found in 71%, 45% and 35% cases for AA, AG and GG genotypes, respectively. The XRCC3 241MetMet variant was significantly associated with increased risk of death (HR= 6.0, 95% CI 3.0 to 40.0, p=0.008); a trend toward a higher recurrence (p=0.07) and worse response (60% vs 43%) was found. Conclusions: XPA and XRCC3 gene defective variants were significantly associated with worse outcome and could predict OS in esophageal cancer patients treated with a neo-adjuvant intensive radio-chemotherapy protocol. Founded by CARIPARO, Italy

No significant financial relationships to disclose.

Women facing HIV. Key question on women with HIV infection: Italian consensus workshop

A panel of leading Italian specialists in infectious diseases, obstetrics and gynaecology met in a national consensus workshop on women facing HIV to review critical aspects and discuss recommendations for selected key questions on four issues: (1) women and highly active antiretroviral therapy (HAART): access to care and adherence to therapy, side effects and drug-drug interaction; (2) HIV-infected pregnant women: prevention of mother to child transmission; (3) desire for children among women living with HIV: assisted reproduction; (4) sexually transmitted diseases and genital disturbances. The method of a nominal group meeting was used, and recommendations were graded for their strength and quality of evidence using a system based on the one adopted by the Infectious Diseases Society of America. Main conclusions are summarized and critically discussed, and some of the most recent data supporting recommendations are provided.

Reproductive assistance for infected couples with bloodborne viruses

During the past 15 years Assisted Reproduction has been facing a new demand from patients requiring ART: couples at risk of partner to partner, and mother to child transmission of viral infections, mainly HIV-1, HCV and HIV-HCV co-infected partners. The general conditions and life expectancy of many patients with HIV infection are very good, and three-quarters of these individuals are in their reproductive years. For these reasons, a large number of young couples are expected to make future plans to have children. This desire is not easy to realize for serodiscordant couples, if we consider that, in order to avoid HIV virus transmission, it is necessary to encourage the condom use in vaginal and anal contacts. On the other hand infertile discordant HCV couples need to be included in protocols of controlled assisted reproduction procedures to avoid any risk of HCV transmission to the partner. In this paper we consider assisted reproduction in discordant couples for HIV or HCV-positive men.

Co-morbidity is a better predictor of 5-fluorouracil pharmacokinetic than chronological age in older adults

9038

Background: Fifty percent of all cancers occur in elderly people and the total cancer burden is expected to rise. Data are needed to ensure the safe administration of chemotherapy in the older patient population. Aging can affect the pharmacokinetics in a number of ways and the selection of chemotherapy in the elderly is frequently and empirically determined by degree of comorbidity and the patients’ functional status. The aim of our study was to determine whether high level of comorbidity, measured using a standardized instrument, can predict 5-fluorouracil (5FU) disposition in older adults. Methods: Geriatric outpatients affected by stage 2 or 3 colorectal cancer and treated with adjuvant MAYO Clinic regimen were the study population. The evaluation was conducted on men aged 70 years old or more, with varying levels of chronic illness. All of them had a good performance status (ECOG score= 0–1). Non neoplastic disease burden was measured using the Cumulative Illness Rating Scale (CIRS) and drug disposition using area under the curve (AUC) of the drug plasma levels during 30 min immediately after 2 minute bolus administration of 5FU 375–425 mg/mq. Results: Forty men were studied, aged between 70 and 80 years old (median = 72); their CIRS scores ranged between 0 and 12 (median=3). Pharmacokinetic analysis confirmed an elevated interpatient variability: 5FU plasma AUC after bolus administration ranged between 241 and 1,140 mg × min/L. There was no correlation between age and comorbidity burden or age and 5FU AUC in that population. On the contrary with increasing comorbidity (increase in CIRS score) there was a proportional increase in 5FU AUC: patients with CIRS score from 0 to 3 (n=22), between 4 and 7 (n=11) and greater than 7 (n=7) had mean AUC of 523.5± 139.6, 637.0±124.0 and 877.4±195.0 mg × min/L respectively (p<0.0001). Conclusions: This study shows that chronological age did nor correlate with CIRS score or 5FU disposition. In older adults with varying degrees of chronic illness, administrated with the same chemotherapy doses, the comorbidity level influenced the magnitude of 5FU exposition, suggesting that the CIRS score could be used to tailor treatment doses. Funded by AIRC-Veneto

No significant financial relationships to disclose.

Pregnancy outcomes and antiretroviral treatment in a national cohort of pregnant women with HIV: overall rates and differences according to nationality

We used data from the main surveillance study of HIV and pregnancy in Italy to evaluate possible differences in pregnancy care and outcomes according to nationality. Among 960 women followed in 2001-06, 33.5% were of foreign nationality, mostly from African countries. Foreign women had lower rates of preconception counselling and planning of pregnancy. They had more frequently HIV diagnosed during pregnancy, with a later start of antiretroviral treatment and lower treatment rates at all trimesters but not when the entire pregnancy, including delivery, was considered. No differences were observed between the two groups in ultrasonography assessments, hospitalisations, AIDS events, intrauterine or neonatal deaths, and mode and complications of delivery. Foreign women had a slightly lower occurrence of preterm delivery and infants with low birthweight. The results indicate good standards of care and low rates of adverse outcomes in pregnant women with HIV in Italy, irrespective of nationality. Specific interventions, however, are needed to increase the rates of counselling and HIV testing before pregnancy in foreign women.

Sonohysterographic endometrial sampling and hysteroscopic endometrial biopsy: a comparative study

OBJECTIVES

To compare the quantity and quality of endometrial tissue sampled at saline contrast sonohysterography (SCSH) with that obtained by directed endometrial biopsy by operative hysteroscopy in patients with diffusely thickened and/or inhomogeneous endometrium at SCSH. A secondary aim was a comparison of the extent of procedure-related pain.

METHODS

One hundred and twenty-eight patients with diffusely thickened (> 4 mm) and/or inhomogeneous endometrium at SCSH were prospectively recruited. Endometrial sampling was performed at the end of SCSH using the same 4.7-mm intrauterine catheter that had been used for saline instillation. These samples were compared to directed endometrial biopsies obtained with the guidance of an office 5-mm hysteroscope. After hysteroscopy, an extended guided curettage was performed under general anesthesia, providing specimens that were considered the gold standard for histological diagnosis. Endometrial specimen area (mm(2)), histologic concordance and procedure related pain (10-cm VAS) were compared for the two techniques.

RESULTS

The median age of 88 pre- and of 40 post-menopausal patients was 41 (interquartile range, 34-48) years and 57 (interquartile range, 52-67) years, respectively. The median area of endometrial specimen obtained by SCSH was 25.1 (interquartile range, 12.4-52.3) mm(2) and was not significantly different from that obtained by hysteroscopy (16.9 (interquartile range, 10.0-52.7) mm(2)). The K values of the two different techniques for typical hyperplasia (n = 61) and for premalignant and malignant lesions (n = 26) were 0.91 and 0.94, respectively. Procedure-related pain was not significantly different between pre- and postmenopausal patients for both sampling techniques.

CONCLUSIONS

SCSH with sampling proved to be as good as and as tolerable as hysteroscopic biopsy in cases with diffusely thickened and/or inhomogeneous endometrium. Both these imaging and biopsy techniques should be considered a reliable outpatient procedure in the management of patients with abnormal uterine bleeding. Published by John Wiley & Sons, Ltd.

Safety of sperm washing and ART outcome in 741 HIV-1-serodiscordant couples

BACKGROUND

To evaluate the safety of sperm washing and assisted reproduction technique (ART) outcome offered to serodiscordant couples with a human immunodeficiency virus-1 (HIV-1)-positive male.

METHODS

Sperm washing was performed and checked by RT-PCR on each semen sample before its fresh usage. Intrauterine insemination (IUI) or IFV/ICSI was offered according to fertility profile of each couple. Non-infected women underwent HIV testing 2 weeks before each procedure and for up to 6 months after.

RESULTS

Seven hundred and forty-one couples entered the study of a possible 2011 serodiscordant couples counselled over 4 years. Superovulation and IUI were performed in 581 couples, where the pregnancy rate per cycle and pregnancy rate per couple were 19 and 78%, respectively, with multiple pregnancy rate being 4%. One hundred and sixty couples were treated by IVF/ICSI, where pregnancy rate per cycle and per couple were 22 and 41%, respectively, with multiple pregnancy rate being 10%. All female partners were still HIV-1 negative at follow-up.

CONCLUSION

Sperm washing within a programme of reproductive counselling was proved to be safe in this large series of serodiscordant couples. The overall pregnancy rate (70.3%), independent of the procedure used (IUI or IVF/ICSI), justifies the effort of the medical team in setting up and implementing dedicated centres and of the individual patient in seeking a safe pregnancy.