Prenatal Diagnosis and Outcome of Congenital Corrected Transposition of the Great Arteries - A Multicenter Report of 69 Cases

OBJECTIVE

 Congenital corrected transposition of the great arteries (ccTGA) is a rare congenital cardiac anomaly which remains difficult to diagnose prenatally. We aim to investigate the natural history, associated anomalies and the outcome of patients in prenatally diagnosed ccTGA.

METHOD

 This was an international multicenter retrospective analysis of fetuses with a diagnosis of ccTGA from 2002 to 2017. We reviewed clinical and echocardiographic databases of seven centers. Anatomic survey and fetal echocardiography were performed according to international guidelines of ISUOG.

RESULTS

 We considered 69 fetuses with prenatally suspected ccTGA. There was an overall survival rate of 91 % among 54 patients with a confirmed diagnosis. Survival to live birth was 96 % (52/54) and survival on an intention-to-treat basis was 94 % (49/52). The mean gestational age at the time of diagnosis was 25.6 ± 5.9 weeks of gestation. In 7 out of 54 fetuses (13 %), ccTGA was an isolated finding. Dextro/mesocardia was present in 15 cases (27.8 %). Intracardiac anomalies were present in 46/54 cases (85.2 %) with the most frequent anomaly being a ventricular septal defect present in 41 fetuses (75.9 %). Complete heart block was diagnosed in 10 cases (18.5 %). Extracardiac anomalies were observed in 9 out of 54 cases (16.7 %). Prenatal karyotyping of the fetus was available in 30/54 (55.6 %) cases with chromosomal anomalies in 4/30 (13.3 %).

CONCLUSION

 ccTGA is a rare cardiac anomaly often accompanied by a variable spectrum of further intracardiac abnormalities. Accurate diagnosis of ccTGA, which can be integrated into parental counselling, is feasible with a favorable short-term outcome for affected neonates.

Long Term Dialysis with Low-Calcium Solution (1.0 Mmol/L) in Capd: Effects on Bone Mineral Metabolism

Objective

Peritoneal dialysate solutions with conventionally high-calcium (Ca) concentrations (1.75 mmol/L) are now widely replaced by solutions with a lower, more physiological calcium content to prevent hypercalcemia in patients treated with oral calcium-containing phosphate binders and/or calcitriol. While there is still debate on how far the dialysate calcium should be lowered (1.25 mmol/L or less), little information is available concerning the effects of a long-term treatment with low-calcium solutions on secondary hyperparathyroidism and bone mineral metabolism in general.

Design

A prospective, randomized, controlled multicenter study to compare the effects of low-calcium (LCa, dialysate calcium 1.0 mmol/L) versus standard calcium dialysate solution (SCa, dialysate calcium 1.75 mmol/L)on bone mineral metabolism in continuous ambulatory peritoneal dialysis (CAPD) patients over 2 years of treatment.

Setting

Nephrology and dialysis units of primary and tertiary hospitals in Germany and Switzerland.

Patients

All CAPD patients in the participating centers between 18 and 80 years of age, stable on CAPD for at least 1 month, free of aluminum bone disease or prior parathyroidectomy were invited to enter the study. Sixty-four patients could be randomly allotted to LCa (n = 35) or SCa (n = 29) treatment in a 2-year protocol; 34 finished the study as planned.

Interventions

Calcium carbonate (CaCO3) was given as oral phosphate binder to maintain serum phosphate <2.0 mmol/L. If hypercalcemia supervened, CaCO3 was exchanged stepwise for aluminium hydroxide (AI(OH)3)’ until normocalcemia was obtained. Patients received calcitriol (0.25 μg/day per os) if parathyroid hormone (PTH) exceeded the upper limit of normal by a factor of 2 or more.

Main Outcome Measures

We assessed total and ionized serum calcium, phosphate, serum aluminum, alkaline phosphatase, osteocalcin, PTH (intact molecule), and phosphate binder intake at regular intervals. Measurements of bone mineral density and hand skeleton x-rays were obtained at the start and after 6 months and 2 years, respectively.

Results

With LCa, mean total and ionized serum calcium levels were within the normal range (total Ca: 2.0 2.6 mmol/L; ionized Ca: 1.19–1.32 mmol/L), but throughout the treatment period were significantly lower than with SCa. The incidence of hypercalcemia (>2.8 mmol/L) was three times higher in patients on SCa, despite the significantly higher amount of AI(OH)3 and less CaCO3 given in this group. In parallel, serum aluminum increased with SCa throughout the study, whereas it was slowly decreasing with LCa. Median PTH levels remained stable at about two times the upper limit of normal over the 2 years of study with LCa. However, 23% of the patients on LCa developed severe hyperparathyroidism, with PTH levels exceeding ten times the upper limit of normal compared to only 10.3% of the patients on SCa. With SCa, median PTH decreased towards near normal levels. Alkaline phosphatase and serum osteocalcin correlated positively with PTH levels. Bone mineral density was in the lower normal range in both groups a n d remained unchanged at the end of the study. Skeletal x-ray films showed only minor alterations in very few patients in both groups with no correlation to serum PTH or treatment modality.

Conclusion

In CAPD patients low-calcium dialysate solutions can be used successfully over prolonged periods of time with stable control of serum calcium. The risk of hypercalcemia resulting from calcium-containing phosphate binders and the need to use aluminum-containing phosphate binders is markedly diminished. However, there is a certain risk that severe secondary hyperparathyroidism with long-term LCa therapy will develop, even if normocalcemia is maintained. Thus, LCa dialysis requires closeand continuous monitoring of PTH and bone metabolism.

Transperitoneal Calcium Mass Transfer using Dialv Sate with a Low Calcium Concentration (1.0 mM)

Lower dialysate calcium concentrations were recently proposed to overcome the risk of hypercalcemia In continuous ambulatory peritoneal dialysis (CAPD) patients on calcium containing phosphate binders and/or vitamin D metabolites using the standard dialysate calcium concentration (sCa) of 1.75 mM.

To assess transperitoneal calcium mass transfer (CaMT) in CAPD patients using a dialysate with a low calcium concentration (LCa, 1.00 mM), 18 stable patients were randomly allocated to receive either LCa or SCa. CaMT was assessed over 4 hours using 2L dialysate bags with three different dialysate glucose concentrations (1.5%, 2.3%, 4.25%). Total serum calcium (tCa), Ionized calcium (iCa), and the exact dialysate volume were measured before and after the 4-hour dwell. A sample of the drained dialysate was obtained to measure the dialysate calcium concentration.

The tCa and iCa levels were not significantly different In both groups prior to and did not change throughout the test. CaMT (median/range) was .0.64 mmol/exchange (0.35 –1.29 mmol/exchange) using LCa with 1.5% glucose compared to 0.23 mmol (.0.18 -0.87 mmol) with SCa (p<0.0001). CaMT was negatively correlated to ICa and ultrafiltration volume [4.25%: LCa -1.22 (.0.84 -1.9); SCa .0.43 (-1.35 -0.13); p<0.001].

In summary, LCa results in a loss of calcium into the dialysate even at low ultrafiltration volumes and serum ICa levels. This might facilitate the prevention and therapy of renal osteodystrophy with calclum-containing phosphate binders and calcitriol. However, patients using LCa must be carefully monitored for calcium homeostasis and bone turnover.

Absent pulmonary valve syndrome - diagnosis, associations, and outcome in 71 prenatally diagnosed cases

OBJECTIVE

The objective of this study was to analyze the spectrum of prenatally diagnosed absent pulmonary valve syndrome (APVS) and the outcome from diagnosis onwards. Fetuses with APVS and tetralogy of Fallot (TOF/APVS) and with APVS and intact ventricular septum (APVS/IVS) were included.

METHOD

Multicenter retrospective study of the International Prenatal Cardiology Collaboration Group. Clinical and echocardiographic databases of nine referral centers were reviewed from 2012-2016.

RESULTS

The cohort included 71 cases, 59 with TOF/APVS and 12 with APVS/IVS. In 18.3% of cases, diagnosis was achieved within first trimester. Association with hydrops fetalis was high within first trimester (69%). No fetus with known outcome survived after first trimester diagnosis. Karyotype anomalies occurred in 45% of cases with known karyotype. Intrauterine fetal demise occurred in 14.3%. Overall survival after initial diagnosis in the total cohort was 28.1% (28.8% TOF/APVS and 25.0% APVS/IVS). Survival to birth was 50% in TOF/APVS and 44.4% in APVS/IVS. Survival of subjects born alive beyond neonatal period was 84.6% in TOF/APVS and 100% in APVS/IVS.

CONCLUSION

Diagnosis of APVS is feasible within first trimester. Outcomes remain guarded, especially if first trimester diagnosis is included into the analysis because of associated karyotypic anomalies, the presence of hydrops fetalis, and patent ductus arteriosus. © 2017 John Wiley & Sons, Ltd.

Sonographic Assessment of the Umbilical Cord

The umbilical cord (UC) is a vital connection between fetus and placenta. It constitutes a stable connection to the fetomaternal interface, while allowing the fetal mobility that is of great importance for fetal development in general and fetal neuromotor development in particular. This combination of mechanical stability and flexibility is due to the architecture of the UC. There is however a range of umbilical cord complications that may be life threatening to the fetus and these too can be explained to a large extent by the cord's structural characteristics. This review article discusses clinically relevant aspects of UC ultrasound.

Double-chamber right ventricle associated with severe fetal cardiac failure

Fetal cardiac defects leading to intrauterine cardiac failure and subsequent fetal hydrops are rare. We report an unusual case of a double-chamber right ventricle leading to progressive fetal cardiac insufficiency and hydrops. The patient was first managed conservatively. Delivery by Cesarean section was performed for a pathological fetal heart-rate tracing at 28 weeks of gestation. The newborn died 4 h postpartum due to generalized cardiac insufficiency.

Clinically significant persistence and enlargement of an antenatally diagnosed isolated choroid plexus cyst

Isolated choroid plexus cysts are usually diagnosed at the time of screening ultrasonography during the second trimester. While they raise the question of underlying chromosomal abnormalities, their clinical course is almost invariably benign with complete resolution often by the third trimester. We report the highly unusual case of a choroid plexus cyst diagnosed at 14 weeks of gestational age with subsequent further enlargement of the cyst, necessitating postpartum neurosurgical intervention.

Large-core needle biopsy for diagnosis and treatment of breast lesions

PURPOSE

Large-core needle biopsy (LCNB) has become a more widely used technique in the evaluation of breast lesions. This study was undertaken to access the accuracy of percutaneous LCNB on breast lesions and the impact on further proceeding.

METHODS

A retrospective review of imaging-guided LCNB of 159 breast lesions was done. 143 LCNB were taken with ultrasound guided automated spring gun biopsy and 16 stereotactic-guided with vacuum-assisted biopsy device. Histology and morphobiological parameters were compared with subsequent material from surgery.

RESULTS

In 113 core biopsies (71%), an infiltrating breast cancer was diagnosed, 5 biopsies (3%) yielded in-situ/atypical lesions and a benign lesion was shown in 38 cases (24%). In 3 cases, insufficient/necrotic material was obtained. 108 patients underwent subsequent surgery. In 100/108 cases (93%), histology on LCNB and surgery was identical. LCNB was false negative in 5 core biopsies (5%). Immunhistochemical stains of hormone receptors, bcl-2, c-erbB-2, p53 and MIB-1 was comparable on LCNB and on surgical material. Based on the results of LCNB, 17/113 patients (15%) with infiltrating carcinoma were primarily treated with hormones or with neoadjuvant therapy. 32/38 patients (84%) with benign lesions were followed up by imaging control.

CONCLUSIONS

In patients with benign lesions on imaging, open biopsies can be avoided by LCNB. In patients with biopsy proven carcinoma, therapy planning is improved. The addition of morphobiological parameters allows early individual treatment.

Prenatal diagnosis and perinatal management of left coronary artery to right atrium fistula

Serious complications due to coronary artery fistulae have been described. Most authors recommend early intervention at the time of diagnosis. We present a case of a fistula originating from a dilated left coronary artery and draining into the right atrium, which was diagnosed prenatally by color Doppler echocardiography. During pregnancy, the echocardiographic findings remained unchanged, and there were no signs of heart failure. After birth, the fistula was confirmed by angiography. Additionally, a persistent left superior vena cava draining into the coronary sinus and a very small ventricular septal defect were detected. The fistula was closed successfully by transcatheter coil embolization. At 17 months old the child was in good clinical condition. Prenatal diagnosis of coronary artery fistulae may be possible and may improve perinatal management and outcome.

Cardiac output and central distribution of blood flow in the human fetus

BACKGROUND

The objectives of this study were to establish reference ranges for left and right cardiac output and to investigate blood flow distribution through the foramen ovale, ductus arteriosus, and pulmonary bed in human fetuses.

METHODS AND RESULTS

A prospective study was performed in 222 normal fetuses from 13 to 41 weeks of gestation with high-resolution color Doppler ultrasound. Cardiac output and ductal flow were calculated by use of vessel diameter and the time-velocity integral. Pulmonary blood flow was expressed as the difference between right cardiac output and ductal flow. Foramen ovale flow was estimated as the difference between pulmonary flow and left cardiac output. Gestational age-specific reference ranges are given for left, right, and biventricular output and volume of ductal blood flow, showing an exponential increase with gestational age. Median ratio of right to left cardiac output was 1.42 and was not associated with gestational age. Right cardiac output was 59% and left cardiac output was 41% of biventricular cardiac output. Median biventricular cardiac output was estimated to be 425 mL. min(-1). kg(-1) fetal weight. Ductal blood flow was 46%, estimated pulmonary flow was 11%, and estimated foramen ovale flow was 33% of biventricular output.

CONCLUSIONS

The study establishes reference ranges for fetal cardiac output and offers insights into the central blood flow distribution in human fetuses from 13 weeks to term. There is a clear right heart dominance. The estimated ratio of pulmonary blood flow to cardiac output is higher than in fetal lamb studies.

[Clinical experience with large-core needle biopsies of the breast and evaluation of histopathology]

OBJECTIVE

Interventional techniques allow a microinvasive diagnostic of breast lesions. We examined the reliability of large core needle biopsies for histologic diagnosis on breast lesions.

MATERIAL AND METHODS

143 ultrasound guided automated spring gun biopsies and 16 stereotactic guided vacuum-assisted device biopsies were analyzed. Indications included confirmation of malign or benign lesions and diagnosis of suspicious lesions.

RESULTS

In 113 biopsies (71%) an invasive breast carcinoma was diagnosed, in 5 biopsies (3%) in situ/atypical lesions were seen and 38 cases (24%) showed benign lesions. Based on the bioptic results, 108 patients underwent subsequent surgery. An identical histology was seen in 100/108 patients (93%), 5 biopsies were false negative (5%) and 3 specimens yielded necrotic/insufficient material. The immunohistochemical results of percutaneous biopsies and surgical specimens were comparable. 17 out of 113 patients (15%) with biopsy proven carcinoma were treated with neoadjuvant therapy. 32/38 patients with benign lesions were follow-up clinically.

CONCLUSION

Ultrasound- or stereotactic guided percutaneous biopsies are methods to confirm histological diagnosis. Based on the biopsy results the, number of surgical excisions can be reduced and treatment of biopsy proven carcinoma can be improved by individual presurgical planing.

Reference ranges for two-dimensional echocardiographic examination of the fetal ductus arteriosus

OBJECTIVES

To establish reference ranges for 2D-echocardiographic examination of the fetal ductus arteriosus and its relationship to the main pulmonary artery and the aorta.

METHODS

A prospective cross-sectional echocardiographic study was performed in 222 normal fetuses from 13 to 41 weeks of gestation using high resolution/color Doppler ultrasound equipment.

RESULTS

Gestational age-specific reference ranges are given for the diameter of the pulmonary valve anulus, diameter of the ductus arteriosus at its beginning, middle, and end, ductal length, ductal diameter-to-pulmonary valve anulus diameter ratio, and the spatial relationship of the ductus arteriosus to the main pulmonary artery and to the aorta.

CONCLUSIONS

The presented data derived from a study group of 222 normal fetuses provide in-vivo insights into the morphology of the ductus arteriosus and its relationship to the adjacent vessels. The reference ranges may be helpful in prenatal diagnosis of cardiac malformations and abnormalities of the ductus arteriosus, such as obstruction or aneurysm from 13 to 41 weeks of gestation.

Blood flow velocity waveforms of the fetal pulmonary artery and the ductus arteriosus: reference ranges from 13 weeks to term

OBJECTIVE

To establish reference ranges for blood flow velocity waveforms of the fetal main pulmonary artery and the ductus arteriosus during the second and third trimesters of pregnancy.

METHODS

A prospective cross-sectional echocardiographic study was performed in 222 normal fetuses from 13 to 41 weeks of gestation using high resolution/color Doppler ultrasound equipment.

RESULTS

Gestational age-specific reference ranges are given for peak velocity across the pulmonary valve, velocities in the ductus arteriosus, peak systolic velocity in the ductus arteriosus-to-peak velocity across the pulmonary valve ratio, ductal systolic velocity-to-diastolic velocity ratio, ductal resistance index and ductal pulsatility index. In the ductus arteriosus, increasing fetal heart rate was significantly associated with increasing end-diastolic velocity and decreasing systolic-to-diastolic ratio, decreasing resistance index, and decreasing pulsatility index.

CONCLUSIONS

Based on a prospective study in more than 200 normal fetuses, the data provide gestational age specific reference ranges for blood flow velocity waveforms of the fetal pulmonary artery and the ductus arteriosus. The reference ranges may be helpful in prenatal diagnosis of cardiac malformations and ductal obstruction from 13 to 41 weeks of gestation.

[Extensive cavernous capillary hemangioma of the right atrium in a newborn infant]

Cardiac hemangiomas in infancy are very rare. We report on a newborn, in whom a tumor of the right artrium was diagnosed in the prenatal period. After complete surgical resection histologic workup showed a cardiac hemangioma.

[Prenatal diagnosis and therapy of feto-fetal transfusion syndrome]

Twin-twin transfusion syndrome (TTTS) is a serious complication of monochorionic twin pregnancies. It is the result of an unbalanced transfusion of blood across placental vascular anastomoses. TTTS appears predominantly in the second trimester of pregnancy characterized by discordance of growth as well as polyhydramnios in the recipient and oligo-/anhydramnios in the donor. Prenatal diagnosis is possible by non-invasive and invasive methods. The prognosis of the untreated TTTS is very poor. Serial amniocenteses and laser therapy are used resulting in survival rates of about 60%. Intrauterine death of one twin is associated with a high risk of morbidity in the surviving twin. Monochroionic twins have to be identified in early pregnancy. Close surveillance is necessary to diagnose TTTS at an early stage of the disease.

Fetal sex determination by high resolution ultrasound in early pregnancy

OBJECTIVE

Fetal sex determination by ultrasound, and its medical and ethical implications, has been predominantly discussed in mid and late gestation. The development of high resolution ultrasound equipment has provided the possibility of detailed visualization of the fetus in early pregnancy. The present prospective study investigates the feasibility and accuracy of fetal sex determination by transabdominal ultrasound in early pregnancy.

METHODS

Sonographic determination of fetal sex was attempted prospectively prior to genetic amniocentesis in 173 fetuses from 11 to 16 weeks of gestation. The result of ultrasound examination was compared with the karyotype obtained from amniotic fluid cells.

RESULTS

Sonographic sex determination was feasible in 80.3% of cases, and all these determinations proved to be correct. There was no difference in the identification rate between male (n=87) and female (n=86) sex. Fetal sex determination was also feasible and correct in all four sets of twins and in the one set of quadruplets.

CONCLUSION

Fetal sex assignment in the late first and early second trimester can be useful in pregnancies at risk for severe sex-linked diseases, in fetal disorders involving the genitalia, and in the individual identification of multiple fetuses. Prenatal sex assignment in early pregnancy implicates also far-reaching ethical problems because of the potential risk of sex-selected abortion.

Circulatory changes following intrauterine closure of the ductus arteriosus in the human fetus and newborn

Prenatal detection of intrauterine closure of the ductus arteriosus unrelated to maternal administration of non-steroidal anti-inflammatory drugs or glucocorticoids made it possible to study the circulation in this condition in the human fetus and newborn by pre- and postnatal echocardiography and neonatal cardiac catheterization. At 38 weeks, the fetus presented intrauterine ductal closure associated with right ventricular dilatation and marked hypertrophy of the right ventricle and the interventricular septum, as well as severely diminished right ventricular fractional shortening and diminished pulmonary blood flow. Blood flow redistribution was characterized by reduced blood flow through the right heart and increased right-to-left shunting across the dilated foramen ovale. Pathological Doppler waveforms of the inferior vena cava and the ductus venosus were found, although the cardiotocogram was normal. Following unsuccessful induction of labour a Caesarean section was performed. Postnatal echocardiography confirmed the prenatal findings. Cardiac catheterization, performed because of persistent dependence on additional oxygen administration, revealed increased pulmonary vascular resistance, reduced pulmonary blood flow, and prolonged right-to-left shunt across the foramen ovale. Reduced peripheral pulmonary artery diameters were shown angiographically. Follow-up examinations revealed regression of right ventricular hypertrophy and recovery of right ventricular and pulmonary function. The findings confirm results from haemodynamic studies in animal experiments.

The predominant protein in peroxisomal cores of sunflower cotyledons is a catalase that differs in primary structure from the catalase in the peroxisomal matrix

This paper describes a biochemical study on the protein composition of crystalline inclusions (cores) from plant peroxisomes. By SDS/PAGE and immunoblotting, a catalase of 59 kDa was identified as the predominant protein component in purified cores from sunflower (Helianthus annuus L.) cotyledons. A 55-kDa catalase was the only additional peptide detected. In contrast to in cores, the 55-kDa catalase was the major catalase protein in matrix fractions obtained from lysed peroxisomes. These findings suggested two peroxisomal populations of catalase differing in molecular structure and subperoxisomal compartmentation in sunflower cotyledons. Evidence for different amino acid sequences of the two catalases was found by peptide mapping with endoproteinase Glu-C, by expressing a cDNA encoding matrix catalase in Escherichia coli, and by partial amino acid sequencing of peptide fragments from 59-kDa core catalase. These results contradict the previous view that the formation of cores occurred via condensation of matrix catalase, and indicate that new concepts on the biogenesis and physiological function of plant peroxisomal cores need to be developed.

Sonographic assessment of the fetal palpebral fissure slant--an additional tool in the prenatal diagnosis of syndromes

Several syndromes and aneuploidies are associated with ocular abnormalities including up- and down-slanting palpebral fissures. We describes a technique for the sonographic assessment of the fetal palpebral fissure slant which was used in 70 normal pregnancies from 14 to 36 weeks of gestation. In a frontal view of the fetal face, the inferior angle between the palpebral fissure and the midline of the skull was determined. The median angle was 89 degrees, with a range from 87 degrees to 90 degrees. In selected cases, sonographic assessment of the fetal palpebral fissure slant may be a helpful additional tool in the prenatal diagnosis of syndromes, as demonstrated in a fetus with Seckel syndrome associated with downslanting palpebral fissures and in a fetus with Down's syndrome associated with upslanting palpebral fissures.

Prenatal detection of double aneuploidy trisomy 10/monosomy X in a liveborn twin with exclusively monosomy X in blood

Both double aneuploidy and trisomy 10 are rare chromosome findings. All five published cases of trisomy 10 in liveborns were found to be mosaic with an euploid cell line. In a liveborn female twin, double aneuploidy mosaicism 47,XX, + 10/45,X was detected prenatally by amniocentesis performed because of severe intrauterine growth retardation and malformations. Chromosome analysis from neonatal lymphocyte cultures revealed exclusively the 45,X cell line. Double aneuploidy mosaicism trisomy 10/monosomy X was confirmed from skin fibroblasts. The child died at the age of 7 weeks. This is the first reported case of double aneuploidy involving trisomy 10, and the first case of trisomy 10 without a normal cell line in a liveborn. Prenatal diagnosis of trisomy 10 in a liveborn has not been published so far. The case illustrates that in specific cases amniotic fluid cells may reflect the karyotype of the fetus better than blood.

An accurate method for sonographic estimation of the weight of very preterm fetuses

This study was undertaken to test the accuracy of formulas we recently developed for the sonographic estimation of the weight of very preterm fetuses. The formulas were used to determine estimated weights from prenatal sonographic data for 62 premature infants born at 23-29 weeks of gestation, weight < or = 1,400 g. The mean absolute deviation of the actual birth weight from the estimated weight was 75.8 +/- (SD) 68.5 g, the mean percent deviation +0.60% and the absolute mean percent deviation 8.1 +/- (SD) 5.6%; 90.3% of the birth weights lay within 15% of the estimated weight. The model described represents an accurate method for prenatal estimation of the weight of very preterm fetuses.

Ductus arteriosus-dependent pulmonary circulation secondary to cardiac malformations in fetal life

The objective of this study was to describe the characteristic prenatal findings of a ductus arteriosus-dependent pulmonary circulation secondary to cardiac malformations. B-mode, color and pulsed wave Doppler echocardiography were performed in seven fetuses with severe pulmonary stenosis or atresia. All findings were confirmed postnatally by echocardiography and cardiac catheterization or autopsy. Severe fetal pulmonary stenosis or atresia was characterized by decreased pulmonary valve diameters, frequently with reduced pulmonary artery diameters, increased flow velocities or absent flow across the stenotic pulmonary valve, increased ascending aorta diameters, slightly increased aortic velocities and normal umbilical and middle cerebral artery Doppler wave forms. In all cases, prenatal assessment of neonatal ductus dependence was possible by demonstrating reverse flow across the fetal ductus with peak systolic velocities ranging from 0.9-2.0 m/s and absent diastolic flow. Ductal diameters were slightly decreased, ranging from 2-4 mm. Prenatal detection of a ductus-dependent pulmonary circulation is a strong indication of the presence of severe pulmonary stenosis or atresia. Its diagnosis allows avoidance of maternal administration of drugs with constrictive effects upon the ductus, interdisciplinary planning of perinatal management, early postnatal confirmation of the diagnosis, and early postnatal intervention, in particular administration of prostaglandins to prevent life-threatening ductal closure.

Late onset of hydrops fetalis following intrauterine parvovirus B19 infection

We present a case of intrauterine parvovirus B19 infection, diagnosed by detection of B19 DNA in the amniotic fluid obtained at 15 weeks of gestation for chromosome analysis in an asymptomatic pregnancy, causing hydrops fetalis 7 weeks later. Following intrauterine transfusion, rapid resolution of hydrops could be observed and a healthy boy was born at 38 weeks of gestation. The respective laboratory data obtained from the examination of the amniotic fluid and maternal, fetal, and neonatal blood offer interesting insights into the dynamics of maternal-fetal parvovirus B19 infection.

Prenatal diagnosis of idiopathic stenosis of the ductus arteriosus associated with fetal atrial flutter

Antenatal stenosis or closure of the ductus arteriosus unrelated to either congenital heart defects or prostaglandin inhibitors is considered to be uncommon, but may result in congestive heart failure, hydrops fetalis, and perinatal death. We report a case of idiopathic ductal stenosis detected prenatally by two-dimensional and Doppler echocardiography in a fetus presenting atrial flutter and right atrial dilatation at 31 weeks of gestation. Prenatal treatment with digoxin and verapamil resulted in conversion to sinus rhythm. The fetus was closely monitored. Congestive heart failure did not develop, and the fetus was delivered spontaneously in good condition at 39 weeks of gestation. In case of ductal stenosis, the potential risk of congestive heart failure must be considered, and maternal administration of drugs with constrictive effects on the ductus arteriosus, as indomethacin or betamethasone, should be avoided.

De novo direct tandem duplication of a small segment of the short arm of chromosome 7 (p21.22-->22.1)

We report a boy with duplication of a small segment of the short arm of chromosome 7 (46,XY, dir dup (7) (p21.2-->22.1). The boy presented with supravalvular pulmonary stenosis, atrial septum defect and mental retardation. The origin of the additional material from chromosome 7 was confirmed by fluorescence in situ hybridization. This technique in combination with the use of single-copy DNA probes may in future help to delineate the phenotype/karyotype correlation.

[Placental location and incidence of pre-eclampsia]

AIM

In pregnancies with unilateral placental location, the uteroplacental Doppler flow measurements show significant side-to-side differences. Highly divergent findings seem to be associated with an unfavourable outcome, particularly with preeclampsia. Therefore, we studied the relationship between placental location and subsequent development of preeclampsia prospectively.

METHOD

184 patients between 24 and 36 weeks of gestation were studied prospectively. Placental location was classified as central or lateral by ultrasound. Preeclampsia was defined by blood pressure > or = 140/90 mmHg and proteinuria > or = 500 mg/24 h.

RESULTS

After consideration of exclusion criteria, 148 pregnancies could be evaluated: 115 had a laterally and 33 a centrally located placenta. The incidence of preeclampsia in these groups was 32/115 (28%) and 3/33 (9%) respectively.

CONCLUSION

These data suggest that a laterally located placenta is associated with a significantly increased incidence of preeclampsia, with a risk ratio of 3.1 when compared to pregnancies with centrally located placentas.

[Vein of Galen malformation: prenatal diagnosis and noninvasive procedure]

In two fetuses a vein of Galen aneurysmal malformation was prenatally diagnosed causing cardiac failure and hydrocephalus associated with marked encephalomalacia. Blood flow in the vena prosencephalica measured by Doppler ultrasonography was extremely high (1290 and 1500 ml/min maximum). In a interdisciplinary council a strictly noninvasive pre- and postnatal procedure was proposed. After adequate information both parents agreed with this approach. The neonates died immediately after birth.

[Doppler sonography of the ductus venosus in high risk pregnancies at 23 and 26 weeks]

Ductus venosus blood flow was assessed in 3 high-risk pregnancies, which were terminated at 23 to 26 weeks' gestation because of HELLP-syndrome. The fetuses were extremely growth-retarded and showed diastolic reverse flow in the umbilical artery. In all cases the ductus venosus flow pattern was abnormal and finally showed loss of blood flow during atrial contraction. This finding suggests that the fetal central venous pressure is pathologically increased and may be interpreted as a sign of threatening cardiovascular decompensation.

Fetal and transient neonatal right heart dilatation with severe tricuspid valve insufficiency in association with abnormally S-shaped kinking of the ductus arteriosus

Alterations of the ductus arteriosus, e.g. occlusion, constriction or aneurysm, can influence the fetal and neonatal circulation. A case of fetal right atrial and ventricular dilatation, severe tricuspid valve insufficiency and transient pulmonary valve regurgitation at 32 weeks of gestation is reported. Structural heart defects and extracardiac diseases (e.g. high output cardiac failure in arteriovenous shunts and anemia) were excluded by Doppler echocardiography and fetal blood sampling. An abnormally S-shaped kinking of the ductus arteriosus with increased systolic and diastolic flow velocities in the distal part was demonstrated. At 35 weeks' gestation, Cesarean section was performed, because of increased tricuspid valve insufficiency, and a healthy boy was born. After birth, right heart dilatation and tricuspid valve insufficiency decreased. The cardiac changes in relation to the anatomical abnormality of the ductus arteriosus are discussed.

A new formula for prenatal ultrasonographic weight estimation in extremely preterm fetuses

A new formula for the prenatal estimation of the weight of extremely preterm fetuses was derived using ultrasound measurements and birth weights of 73 premature infants delivered before 30 completed weeks of pregnancy and weighing between 400 and 1,680 g at birth. The actual birth weight lay within +/- 15% of the estimated weight calculated with this formula in 92% of the cases. Preliminary testing of the reliability of the formula was performed on a further test group of 19 nonselected cases. The formula developed in this study offers a reliable and simple method of prenatal estimation of fetal weight between 23 and 30 weeks of gestation.

Calcium ionophores injure alveolar epithelial cells: relation to phospholipase activity

Phospholipases and certain of their hydrolytic products are toxic to alveolar epithelial cells. Since many intracellular phospholipases are Ca2+ dependent, we postulated that elevating cytosolic Ca2+ with ionophores might cause epithelial injury via phospholipase activation. Isolated perfused hamster lungs exposed to an Ca2+ ionophore A23187 develop functional evidence of severe epithelial injury. Ultrastructural studies show widespread lysis of type I epithelial cells, with only minimal abnormalities in other lung cells, including the microvascular endothelium. Analysis of whole lung lipid extracts reveals a modest elevation in free arachidonic acid but no changes in other putative products of phospholipase activity. Parallel studies were performed in cultured cells of pulmonary origin. As measured by 51Cr release, A23187 causes substantial cytotoxicity in 3-day-old cultures of rat type II alveolar epithelial cells (RAEC) but not in cultured bovine pulmonary artery endothelial cells (BPAEC). RAEC prelabeled with [14C]stearic acid [( 14C]SA) and [3H]arachidonic acid [( 3H]AA) release radiolabeled free fatty acids (FFA) in response to A23187 in a dose- and time-dependent manner that parallels the cytotoxicity index. Analyses of putative phospholipase products in cells radiolabeled with [14C]SA and [3H]AA, with [14C]choline, or with [14C]ethanolamine suggest that liberation of radiolabeled FFA may be due to several phospholipases but with principal activity being exhibited by a phospholipase C having specificity toward phosphatidylcholine and phosphatidylethanolamine. Prelabeled BPAEC release only minimal quantities of FFA in response to A23187 under the same conditions. These studies demonstrate that elevations of intracytoplasmic Ca2+ are capable of severely and selectively damaging alveolar epithelial cells and that the injury is associated with activation of intracellular phospholipases. These findings may have implications in regard to the pathogenesis of acute lung injury in humans.

[Olfactory stimulation and contingent negative variation (CNV) (author's transl)]

In addition to olfactory evoked responses (Fig. 1a) the vertex-negative voltage shift was registered in 20 normal adults. Fig. 2 shows this potential for an olfactory indicative stimulus followed by a tone burst or flash sequence, which are stopped by the test person's manual reaction. In Fig. 3 two alternating odorous stimuli are presented, one of which is followed by the tone. The selective expectancy wave is followed by the tone. The selective expectancy wave is only built up by the marked olfactory stimulus. For the first time CNV can be used as a clinical investigation tool to confirm central perception of odorous stimuli and furthermore to objectivate impaired central odour discrimination (parosmia).