Comparison of hemodynamic and respiratory outcomes between two surgical positions for percutaneous nephrolithotomy: a prospective, randomized clinical trial

INTRODUCTION

Percutaneous nephrolithotomy (PCNL) has become the gold standard for the treatment of large and complex kidney stones.

OBJECTIVES

The objective of this study is to evaluate the efficacy and safety of percutaneous nephrolithotomy (PCNL) for patients in the flank position versus prone position.

METHODS

In our prospective randomized trial, 60 patients who would undergo fluoroscopy and ultrasound-guided PCNL in prone or flank position were divided into two groups. Demographic features, hemodynamics, respiratory and metabolic parameters, postoperative pain scores, analgesic requirements, amount of fluid given, blood loss and transfusion, duration of operation and hospital stay, and perioperative complications were compared.

RESULTS

PaO2, SaO2, SpO2 and Oxygen Reserve İndex (ORi) at the 60th minute of the operation and in the postoperative period, Pleth Variability index (PVi) at the 60th minute of the operation, driving pressure in all time periods and the amount of bleeding during the operation were determined to be statistically significantly higher in the prone group. There was no difference between the groups in terms of other parameters. Was found to be statistically significantly higher in the prone group.

CONCLUSIONS

Due to our results the flank position can be preferred in PCNL operations, considering that the position should be chosen according to the surgeon's experience, the patient's anatomical and physiological data, positive effects on respiratory parameters and bleeding, and the operation time can be shortened as the experience increases.

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

The Effect of High Lactate Level on Mortality in Acute Heart Failure Patients With Reduced Ejection Fraction Without Cardiogenic Shock

BACKGROUND

We aimed to determine the effect of blood lactate levels on cardiovascular (CV) death and hospitalization for heart failure (HF) in acute HF patients with reduced left ventricular ejection fraction (EF).

METHODS

Eighty-five acute HF patients with reduced ejection fraction were divided into two groups according to admission blood lactate levels. 48 of them had low blood lactate levels (< 2 mmol/l) and 37 of them had high blood lactate levels (≥ 2 mmol/l). Patients with acute coronary syndrome, cardiogenic shock, sepsis and low blood pressure at admission were excluded from the study. Primary endpoint is the composite of cardiovascular (CV) death and hospitalization for heart failure (HHF) in 6-month follow-up. Secondary endpoint is the change in NT-proBNP levels from admission to 72 h.

RESULTS

Baseline characteristics of patients were similar in two groups. On baseline echocardiographic evaluation; patients with high lactate revealed a higher mitral E/A ratio (2.34 [0.43-3.31], p = 0.008) and a lower TAPSE ratio (14 [10-27], p = 0.008) than patients with low lactate levels. Over a median follow-up period of 6 months, the primary end point occurred in 28 (75.7%) of 37 patients assigned to high lactate group and in 20 (41.7%) of 48 patients assigned to low lactate group (p = 0.006). High lactate levels significantly increased the risk of CV death and HHF at 6 months by nearly 5.35-fold in acute HF patients with reduced EF. The change in NT-proBNP levels at 72nd hour after admission were similar between two groups.

CONCLUSION

Higher lactate levels at admission related with higher HHF at 6 months and may be related with higher risk of CV death in acute HF patients with reduced EF.

Mean Platelet Volume and Related Factors in Patients at Different Stages of Diabetic Nephropathy

Introduction:

Mean platelet volume (MPV) is an independent cardiovascular disease predictor, and characteristics of MPV in patients with diabetic nephropathy (DN) are not well known.

Aim:

To determine the MPV levels in patients at different stages of DN.

Patients and Methods:

The MPV levels were investigated in healthy participants (group 1, n = 157), patients with type 2 diabetes mellitus without complication (group 2, n = 160), diabetic patients with clinical proteinuria (group 3, n = 144), and in patients with chronic kidney disease due to DN (group 4, n = 160).

Findings:

The MPV level was higher in all diabetic patients than that in normal participants ( P < .05). The MPV values had a positive correlation with the serum creatinine and proteinuria, and a negative correlation with the glomerular filtration rate ([GFR] P < .001 for all, r values; .72, and .82, and −.92, respectively).

Conclusion:

The MPV values were higher in diabetic groups than that in normal participants. Both GFR and proteinuria were the most powerful determinants of MPV.

Prediction of wastewater dilution and indicator bacteria concentrations for marine outfall systems

This paper describes a modeling study of near-field and far-field dilution of discharged effluents from a deep sea outfall system in Antalya Bay of Turkey. Initial dilution and wastewater plume behavior were simulated by Visual Plumes-UM3 model whereas Brooks dispersion model and first order bacterial decay formulations were used to simulate far-field dilution. The input data sets were collected by detailed field and lab investigations for effluent discharges (flow rate, total and fecal coliform concentration) and ambient environment (oceanographic and current measurements). Geostatistical methods and GIS were used to visualize results of the bacteriological sampling study. Site specific bacterial inactivation rates were determined by both in-situ and lab-scale experiments. Total dilution values and bacteria concentrations were predicted. Good agreement between predicted and measured total and fecal coliform concentrations were obtained for homogeneous and density stratified ambient conditions. Discussion on wastewater dilution mechanisms was presented with recommendations for similar future studies.

A female patient with congenital pouch colon (CPC): a case report

Congenital short colon, more commonly known as pouch colon, is a rare anomaly that can be encountered with anorectal malformations (ARM). The colon is shorter than normal and the distal end is dilated like a pouch. We report the case of a newborn with a Type 2 pouch colon. A female newborn was brought to our clinic with a diagnosis of cloaca anomaly. Her physical examination revealed a single canal introitus and flat perineum. In the abdominal x-ray taken in the upright position, a prominent air sac was noticed at the left side. A laparotomy was performed and exploration demonstrated that the colon was like a pouch. The pouch terminated in the upper part of the vagina with a wide canal. A genitogram displayed the presence of double uteri and double vaginas. One month after the operation we performed a cystoscopy, which showed the urethral meatus to be more proximal than normal (female type hypospadias). When the patient was 8 months old she was re-operated and anterior-abdomino-posterior sagittal anorectoplasty plus tube coloplasty were performed. She is now 4 years old and has a stool discharge of 2-3 times a day. Her physical and psychosocial development is in concordance with her age. Congenital pouch colon is a very rare anomaly, which has to be considered especially during the clinical evaluation of children with cloacal malformations and high type anorectal anomalies.

Development of high-output heart failure after correction of central venous occlusion: a case report

Temporary or permanent central venous catheter (CVC) insertion has been performed frequently for hemodialysis treatment. One of the most important long-term complications of CVC is the central venous occlusion (CVO). Treatment of CVO consists of percutaneous angioplasty (PTA), PTA and stent implantation, or surgical procedure for resistant occlusions. Clinical outcome and long-term results of the revascularization procedures are well documented. However, there is no clear information about acute medical complications of the procedures. High-output heart failure (HOHF) is associated with several diseases including chronic anemia, psoriasis, systemic arteriovenous fistula, sepsis, hypercapnia, multiple myeloma, and hyperthyroidism. Herein, we report a case of chronic kidney disease with CVO that developed acute HOHF immediately after the revascularization procedure (PTA and stenting).

Mitral valve-tricuspid valve distance as a sonographic marker of trisomy 21

OBJECTIVE

Pathologic studies suggest that a decreased mitral valve-tricuspid valve distance (MTD) is found in trisomy 21 fetuses without cardiac defects. We assessed the feasibility of using the MTD as a second-trimester sonographic marker for trisomy 21.

METHODS

We performed a retrospective case-control study of all cases of trisomy 21 at our institution from 1998 to 2008. Cases without a prenatally identified cardiac defect and with adequate images from 15 to 26 weeks' gestation were assessed. The distance between the medial insertions of the mitral and tricuspid valves (i.e. the MTD) onto the ventricular septum was obtained. We also obtained the MTD from normal controls during the study period. Multiple linear regression analysis was used to assess the effects of gestational age and trisomy 21 on MTD. Gestational age-specific percentiles and multiples of the median were calculated, and curves were fitted using linear regression analysis.

RESULTS

We identified 57 trisomy 21 fetuses with a measurable MTD and compared these with 634 control fetuses. Multiple linear regression analysis revealed a positive correlation between MTD and gestational age and a negative correlation between trisomy 21 and MTD. Using a cut-off of the 5(th) percentile, the MTD detected 70% of trisomy 21 cases with a 3.8% false-positive rate in the controls.

CONCLUSIONS

The MTD increases with gestational age and is lower in fetuses with trisomy 21. Twenty (35%) of the 57 cases had no sonographic marker of trisomy 21 except an MTD below the 5(th) percentile for gestational age. The MTD was a useful independent marker for trisomy 21 in the second trimester.

P-wave dispersion in endogenous and exogenous subclinical hyperthyroidism

BACKGROUND

The aim of this study was to measure maximum P wave duration (Pmax) and P wave dispersion (PWD), which can be indicators for the risk of paroxysmal atrial fibrillation when increased, and to reveal their relationship with thyroid hormone levels in patients with endogenous and exogenous subclinical hyperthyroidism.

METHODS

Seventy-one patients with sublinical thyrotoxicosis (34 endogenous, 37 exogenous) and 69 healthy individuals were enrolled in the study. Pmax and minimum P wave duration (Pmin) on electrocardiogram recordings were measured and PWD was calculated as Pmax-Pmin.

RESULTS

Pmax (p<0.001) and PWD (p<0.001) values were significantly higher in patients with endogenous subclinical hyperthyroidism compared with the control group. Pmax (p<0.001) and PWD (p<0.001) values were significantly higher in patients with exogenous subclinical thyrotoxicosis compared with the control group. Pmax (p=0.710) and PWD (p=0.127) were not significantly different in patients with endogenous subclinical hyperthyroidism compared with exogenous subclinical hyperthyroid patients. Pmax and PWD negatively associated with TSH in endogenous and exogenous subclinical hyperthyroidism.

CONCLUSION

In the present study, we observed that Pmax and PWD were longer in patients with endogenous and exogenous subclinical hyperthyroidism. Lack of a difference in Pmax and PWD between patients with endogenous and exogenous subclinical hyperthyroidism seems to support the idea that hormone levels rather than the etiology of thyrotoxicosis affect the heart.

Elevation of the serum total and free prostate specific antigen levels after stent implantation in patients with coronary artery disease

BACKGROUND

Prostate specific antigen (PSA) is the most important biochemical marker in the diagnosis and follow-up of patients with prostate cancer. In recent years, a relationship between PSA levels and cardiovascular conditions has been described. However, no study has investigated the PSA levels after coronary stenting.

AIM

To investigate the impact of coronary stent implantation on serum total PSA (tPSA) and free PSA (fPSA) levels.

METHODS

This study involved 60 men who underwent coronary angiography for suspected coronary artery disease. Of these, 25 were diagnosed as having angiographically normal coronary arteries (Group 1) and 35 underwent coronary stent implantation (Group 2). Serum tPSA and fPSA levels and f/tPSA ratios were determined in all patients immediately before the intervention and 24 hours and 30 days after the procedure.

RESULTS

In Group 1, there was no statistically significant change in the values of tPSA, fPSA and f/tPSA ratio before and after coronary angiography (p >0.05). In Group 2, tPSA and fPSA values 24 hours after stent implantation were significantly higher than the values at the baseline (p <0.01), whereas f/tPSA ratio did not change (p >0.05). Compared with the baseline, there was no statistically significantly difference in the PSA values 30 days after stent implantation (p >0.05).

CONCLUSIONS

This study demonstrated that serum tPSA and fPSA levels are increased after coronary stent implantation, but f/tPSA ratio is not affected. The findings suggest that serum tPSA and fPSA levels should not be used for the diagnosis of prostate cancer during the first 30 days after coronary stenting.

The contribution of 3D-CISS and contrast-enhanced MR cisternography in detecting cerebrospinal fluid leak in patients with rhinorrhoea

The aim of this prospective study was to evaluate the value of unenhanced (three-dimensional constructive interference in steady state (3D-CISS)) and contrast-enhanced MR cisternography (CE-MRC) in detecting the localisation of cerebrospinal fluid (CSF) leak in patients with rhinorrhoea. 17 patients with active or suspected CSF rhinorrhoea were included in the study. 3D-CISS sequences in coronal and sagittal planes and fat-suppressed T1-weighted spin-echo sequences in three planes before and after intrathecal contrast media administration were obtained. Images were obtained of the cribriform plate and sphenoid sinus. In addition, high-resolution CT (HRCT) was performed in order to evaluate the bony elements. The leak was present in 9/17 patients with 3D-CISS and 10/17 patients with CE-MRC. The leak from the cribriform plate to the nasal cavity in six patients and from the sphenoid sinus in four patients was nicely shown by CE-MRC. Eight of those patients were surgically treated, but spontaneous regression of the symptoms in two precluded any intervention. The leak localisations shown with CE-MRC were fully compatible with surgical results. The sensitivities of HRCT, 3D-CISS and CE-MRC for showing CSF leakage were 88%, 76% and 100%, respectively. In conclusion, 3D-CISS is a non-invasive and reliable technique, and should be the first-choice method to localise CSF leak. CE-MRC is helpful in conditions when there is no leak or in complicated cases with a positive beta2-transferrin measurement.

Unusual aortic localization of a malignant epithelial tumor metastasis of unknown origin

Both primary aortic tumors and aortic metastasis of primary cancers is extremely rare. In most cases, diagnosis is established late in the course of the disease and management is challenging. We present a unique case of a 68-year-old woman with an unusual aortic localization of a metastasis of unknown origin.

Effect of hysterectomy on ovarian blood supply and function

Ovarian blood supply and function were assessed before and after hysterectomy in 43 patients and 30 healthy subjects (control group). Before the hysterectomy, transvaginal colour Doppler resistance index values of ovarian artery and hormonal levels were measured. Five days and 6 months after operation, all these measurements were repeated and compared with those of a control group. The sole hormone whose serum level decreased on the 5th postoperative day was oestradiol. Serum levels of all the other hormones remained unchanged 5 days and 6 months after the surgical operations. We also did not find any statistically significant difference between the preoperative, the postoperative and the control group resistance index of the ovarian arteries. We propose that the decision whether to preserve or remove the ovaries must be based on assessment of their functional status. Advantages and disadvantages of leaving ovaries intact should be carefully evaluated and the most useful approach applied to each patient on an individual basis.

Two cases of Guillain-Barré syndrome during measles elimination campaign in Izmir

The authors report two cases of Guillain-Barré Syndrome (GBS) occurred during a national measles vaccination campaign in Izmir, Turkey. Among more than 325,000 vaccine recipients, only 2 cases of GBS were observed within the 10-week risk period. These cases yielded an incidence of 0.615 per 100,000 vaccine doses. The authors think that association between measles vaccination and GBS is coincidental, rather than causal. However, an epidemiological evaluation in Turkey is needed to clearly show that there is no causal association between measles vaccination and GBS.

Direct stenting versus predilatation and stenting technique when using paclitaxel-eluting stents

Direct stenting without predilatation is a well-defined, feasible method with bare metal stents. Direct stenting has also been shown to be safe and feasible with drug-eluting stents, however, there is much less evidence with this type of device when compared with bare metal stents. Three hundred and sixty-four coronary lesions in 257 consecutive patients (mean age, 57.4 +/- 9.8 years; 63 women) who had undergone elective stenting either with or without predilatation via a paclitaxel-eluting stent between March 2003 and March 2006 were retrospectively analyzed. Quantitative coronary angiography analysis was compared between the two groups of procedures; stenting with predilatation and direct stenting. All procedures were uneventful. No deaths occurred during the follow-up period. Direct stenting when compared with the predilatation technique, significantly decreased both procedure time (32.1 +/- 17.9 minute versus 41.2 +/- 18.6 minute, P < 0.0001) and fluoroscopy time (10.6 +/- 7.8 minute versus 15.5 +/- 7.6 minute, P < 0.0001). There was no difference in quantitative analysis parameters of coronary angiography during follow-up or the rates of stent thrombosis and restenosis. Direct stenting seems to be as feasible and safe as conventional predilatation and stenting in selected cases. Direct stenting seems to decrease procedural time and radiation exposure without any negative effect on quantitative analysis parameters of coronary angiography with approximately a one-year follow-up period.

Unusual association of omphalocele and wandering spleen

A wandering spleen is a rare anomaly and its association with omphalocele has been reported in the literature only once. We present a female infant that has a wandering spleen associated with omphalocele. The patient was admitted with the diagnosis of omphalocele. Primary repair was performed and the patient was discharged on the 6th postoperative day. Nine months later, the girl was referred to our emergency unit with complaints about abdominal distention and restlessness. After 2 days of clinical observation, an immobile, firm abdominal mass was palpated. Ultrasonographic evaluation revealed that the mass was the spleen and it was found exactly under the left side of the umbilicus, instead of its original location. During the operation, the spleen was beneath the left side of the umbilicus, with its upper surface completely adhered to the peritoneum, and it was rotated 180 degrees clockwise. Then the spleen was rotated back and placed in its normal anatomic location. At 1 month postoperatively, a radionuclide scan was performed and splenic perfusion was evaluated to be normal. In conclusion, herniations and eventrations of organs through defects on the abdominal wall may either result in restriction of normal rotations of the stomach and the spleen or in inefficient fusion after the rotation has been completed.

Carotid artery intima-media thickness correlates with intravascular ultrasound parameters in patients with slow coronary flow

BACKGROUND

Coronary slow flow (CSF) phenomenon is characterized by delayed opacification of coronary vessels in a normal coronary angiogram. Although clinical and pathological features have been previously described, the underlying pathophysiology has not been fully elucidated. We aimed to determine and compare the carotid intima-media thickness (CIMT) values of SCF patients and healthy subjects, and to correlate patients' values with intimal thickness and TIMI frame counts of their coronary arteries (assessed by intravascular ultrasound).

METHODS

The study population consisted of 50 patients with SCF [38(76%) male, aged 53+/-7 years] and 40 normal subjects [22(55%) male, aged 51+/-8 years]. CIMT values, intravascular ultrasonographies and TIMI frame counts of the patients, and CIMT of the controls were investigated.

RESULTS

Upon intravascular ultrasonography investigation, the common finding was longitudinally extended massive calcification throughout the epicardial coronary arteries in 44 (88%) of patients. Mean coronary intimal thickness was 0.52+/-0.1mm. CIMT was significantly increased in SCF patients than controls (0.84+/-0.14 vs. 0.66+/-0.13, p<0.0001). Besides, CIMT was significantly correlated with coronary intima-media thickness. TIMI frame counts were positively correlated with CIMT and coronary intimal thickness (p<0.05 and p<0.05 respectively).

CONCLUSION

These results support the theory that SCF is the result of coronary atherosclerosis which is the part of systemic involvement.

Crataegus orientalis associated multiorgan hypersensitivity reaction and acute renal failure

Patients, especially those with chronic disease and disorders are increasingly relying on complementary and alternative medical therapies (CAMT). Because the use of CAMT is escalating worldwide, it is essential to be aware of the clinical and adverse effects, doses and potential drug-herb interactions. Crataegus orientalis or hawthorn is a small tree with red fruits. A number of studies appear to demonstrate that Crataegus spp. have a clinically detectable positive cardiac inotropic action. The ingredients, characteristics of metabolism and elimination, and adverse effects of hawthorn remain largely unknown. We report a case of multisystem hypersensitivity reaction and progressive acute renal failure associated with the consumption of Crataegus orientalis.

The Influence of Hemodialysis on P-Wave Signal-Averaged Electrocardiogram Findings

The role of P-wave signal-averaged electrocardiography (P-SAECG) in the prediction of atrial fibrillation (AF) attacks has been validated in various disease states. In the present study, we aimed to investigate the effect of hemodialysis (HD) on P-SAECG parameters and to determine the related risk factors that might affect those parameters. Ninety-one HD patients and 68 controls were included. Hemoglobin levels, serum electrolytes, arterial pH, and interdialytic weight changes were assessed. P-wave duration (PWD) and late potentials of P wave (root-mean-square voltage for the last 20 ms of the signal-averaged P wave [LP20]) were determined by P-SAECG. Pre- and postdialysis PWDs were significantly increased in HD patients than in controls (both P < 0.05), while the voltages of pre- and postdialysis LP20 were significantly reduced (both P < 0.05). A significant increase in PWD (P < 0.05) and a significant decrease in LP20 (P < 0.05) were observed following HD. Pre- and postdialysis PWDs and LP20 were correlated with age (all P < 0.05), dialysis duration (all P < 0.05), and left atrial diameters (LADs) (pre- and postdialysis) (all P < 0.05). Intradialytic changes in serum potassium levels were only correlated with postdialysis PWD and LP20 in HD patients (both P < 0.05). HD seems to increase PWD and to reduce LP20. Advanced age, duration of HD, intradialytic change in serum potassium levels, and LAD seem to be the important associates of P-SAECG parameters in HD patients.

Angiographic and clinical outcome following sirolimus-eluting stent (Cypher) implantation. A single center experience

OBJECTIVES

To investigate the late outcomes of sirolimus-eluting stent implantation in patients with coronary artery disease.

BACKGROUND

Drug-eluting stents reduce intimal hyperplasia, which is the main cause of in-stent restenosis. Sirolimus-eluting stents significantly reduce clinical and angiographic restenosis and improve event-free survival.

METHODS

The study population consisted of 207 patients (273 stents) who had undergone coronary Cypher stent implantation. Patients were eligible for enrollment if there was symptomatic coronary artery disease or positive exercise testing, and angiographic evidence of single or multivessel disease with a target lesion stenosis of > or = 70% in a > or = 2.25 mm vessel. Follow-up coronary angiography was performed 18 months after stent deployment. Patients were followed-up for a mean of 24.7 +/- 7.4 months.

RESULTS

All patients survived after stent implantation, but 5 (2.4%) patients experienced acute ST elevation myocardial infarction and 4 (1.9%) patients developed non-Q wave myocardial infarction following angioplasty. Recurrent angina pectoris was observed in 16 (7.7%) patients (11 stable angina pectoris and 5 unstable angina pectoris). Angiographic evidence of restenosis was observed in these 20 (9.66%) patients. The 5 other patients had noncritical angiographic restenosis. Eleven (5.3%) patients underwent angioplasty because of restenosis, and coronary artery bypass grafting was conducted in the other 9 (4.3%) patients.

CONCLUSION

The results of the present study indicate that Cypher stents could be implanted with a very high success rate and have encouraging long-term angiographic and clinical results.

Changes in fetal hemodynamics with ritodrine tocolysis

OBJECTIVE

To evaluate the effect of ritodrine on the fetal cardiovascular system.

METHODS

Cardiac and extracardiac Doppler waveforms were recorded in 12 fetuses prior to and during ritodrine therapy used for preterm labor. Maternal and fetal heart rates, the Doppler pulsatility indices of the umbilical artery, middle cerebral artery, descending thoracic aorta and renal artery, and time velocity integrals of the atrioventricular valves and the ductus arteriosus, were measured.

RESULTS

Ritodrine infusion caused an increase in maternal and fetal heart rates, the left cardiac output as measured by the product of time velocity integral and heart rate, and the pulsatility index of the middle cerebral artery, and a decrease in the pulsatility index of the umbilical artery.

CONCLUSIONS

Ritodrine infusion may alter placental and cerebral blood flow and may have a selective effect on the left side of the heart.

Fetal arterial and venous Doppler parameters in the interpretation of oligohydramnios in postterm pregnancies

OBJECTIVE

The objective of the current study was to evaluate fetal arterial and venous Doppler parameters in postterm pregnancies with oligohydramnios and those with normal amniotic fluid.

STUDY DESIGN

A cross-sectional study was performed in 38 pregnancies beyond 41 weeks' gestation. Pulsed Doppler imaging was used to determine the pulsatility index (PI) for the fetal middle cerebral artery (MCA), renal artery, umbilical artery, inferior vena cava (IVC) and ductus venosus. The amniotic fluid index (AFI) was used for semiquantitive assessment of amniotic fluid volume. Oligohydramnios was defined as an AFI < 5 cm.

RESULTS

Oligohydramnios was detected in 10 cases, and a normal AFI was present in 28 cases. In the presence of oligohydramnios the PI of the MCA was decreased, while the renal artery PI and the MCA PI/UA PI ratio were found to be elevated. In cases of oligohydramnios the PI in the IVC was increased but was unchanged in the ductus venosus.

CONCLUSION

Oligohydramnios in post-term pregnancies is associated with arterial redistribution of fetal blood flow typifying the brain sparing effect and with decreased resistance in the MCA and increased resistance in the fetal IVC.

Cytogenetical diagnosis in paraffin-embedded fetoplacental tissue using comparative genomic hybridization

Comparative genomic hybridization (CGH) is a FISH-related technique used to assess global chromosomal aberrations in a variety of human tumours. Recently CGH has been applied to cytogenetic analysis of fresh frozen fetoplacental tissues. Here we report the application of CGH to paraffin-embedded placental samples. Ten samples from paraffin-embedded blocks of 6 control placentas and fetoplacental tissue from 10 aneuploidies, and 2 unbalanced aberrations were evaluated. Balanced karyotype profiles were obtained from samples of healthy placentas and all samples from the same placenta appeared to have similar confidence intervals. CGH analysis of four cases of trisomy 21, three cases of trisomy 18, one case of trisomy 13, one case of trisomy 15 and one case of trisomy 7 all showed overrepresentation of the respective trisomic chromosome. The CGH profile was also in accordance with the karyotyping of a case with isochromosome 21. The CGH profile of a case with der (2)t(2;6)(q37.3;q22.2) revealed partial trisomy for chromosome 6 between q21 and q27. CGH may be a useful adjunct in prenatal genetic diagnosis when retrospective diagnosis is needed from archival samples.

Can a single measurement of amniotic fluid delta optical density be safely used in the clinical management of Rhesus-alloimmunized pregnancies before 27 weeks' gestation?

BACKGROUND

To assess the efficacy of a single measurement of amniotic fluid optical density deviation at 450 nanometers in predicting fetal anemia in Rhesus-alloimmunization before 27 weeks gestation.

METHODS

In this cross-sectional study, fetal blood and amniotic fluid samples from 43 Rhesus-alloimmunized pregnancies at 18 to 26 weeks gestation were obtained under ultrasound guidance. Amniotic fluid samples were scanned by spectrophotometry for optic density at various wavelengths. Deviation at 450 nanometers was calculated between 550 and 365 nanometers. The fetuses were divided into three groups based on their hematocrit levels and the predictive efficacy of optic density zones for anemia was evaluated.

RESULTS

A high number of false positive and false negative results were observed when the delta-amniotic fluid optical density of fetuses at risk for anemia was plotted to the zones recently proposed to manage Rhesus-alloimmunized pregnancies.

CONCLUSIONS

These data confirm previous results that the diagnosis of fetal anemia in Rhesus-alloimmunized pregnancies before 27 weeks' gestation cannot be accurately made by a single measurement of amniotic fluid optical density at 450 nanometers.

Arterial and venous Doppler velocimetry in the severely growth-restricted fetus and associations with adverse perinatal outcome

OBJECTIVE

To evaluate the association between arterial and venous Doppler waveforms and adverse perinatal outcome in severe intrauterine growth restriction.

DESIGN

Fetuses between 26 and 32 weeks' gestation with ultrasonographically estimated fetal weight below the 5th centile were included in this prospective study. The last Doppler measurements of the umbilical artery, ductus venosus, umbilical vein and middle cerebral artery before delivery and adverse outcome parameters without gestational age independence were used for statistical analysis. Adverse outcome parameters were defined as the following: fetal demise or neonatal death in the first 30 days of life; 5-min Apgar score of < 7; intubation at birth; retinopathy of prematurity; respiratory distress syndrome; necrotizing enterocolitis; stay in neonatal intensive care unit of more than 60 days; intraventricular hemorrhage; periventricular leukomalacia.

RESULTS

Nineteen fetuses fulfilled the inclusion criteria. Perinatal death, low 5-min Apgar values and necrotizing enterocolitis were gestational age-independent adverse outcome parameters. Abnormal Doppler velocimetry of the ductus venosus was the only significant parameter associated with perinatal death and low 5-min Apgar scores. None of the Doppler parameters predicted necrotizing enterocolitis.

CONCLUSION

Our data suggest that management of severely growth-restricted fetuses may be aided by the study of ductus venosus Doppler velocimetry.

The effect of intravascular blood transfusion on the flow velocity waveform of the portal venous system of the anemic fetus

Our objective was to assess flow velocity waveforms of the portal venous system of the anemic fetus prior to and immediately following intravascular transfusion. Color-guided pulsed Doppler was used to obtain flow velocity waveforms from the fetal portal vein in 14 anemic fetuses that were transfused in utero for rhesus alloimmunization The portal vein velocity pattern was defined as continuous when no change in velocity during the cardiac cycle was noted. It was defined as pulsatile when a deflection of the wave was present. The flow velocity waveforms were quantified by using the ratio between the peak (highest, H) and the nadir (lowest, L) velocities (H/L ratio). Fourteen intravascular transfusions were performed. Gestational age ranged from 19.5 to 35 weeks (mean +/- SD, 26.7 +/- 5.3 weeks). The hematocrit ranged from 5.9 to 31.2% (mean +/- SD, 20.3 +/- 9%) prior to transfusion; after transfusion it was between 24.8 and 56.7% (mean +/- SD, 42 +/- 10.4%). In six cases (43%) the waveforms were pulsatile prior to transfusion; in the other eight (57%) they were continuous. The pulsatile pattern was present following transfusion in 13 cases (93%, p < 0.05). The mean of the H/L ratio was 1.3 +/- 0.38 prior to transfusion and 2.0 +/- 0.86 after transfusion (p < 0.05). Because the portal vein has continuous non-pulsatile flow in the normal fetus, the presence of pulsatility in the waves of six anemic fetuses (43%) may suggest portal hypertension. Compared to normal fetuses, there was an increased number of cases with pulsation, and even more so after transfusion. The pattern corresponds to findings in children with portal hypertension.

Increase of fetal hematocrit decreases the middle cerebral artery peak systolic velocity in pregnancies complicated by rhesus alloimmunization

Our hypothesis for this study was that an increase in fetal hematocrit would decrease the middle cerebral artery peak systolic velocity. Seventeen pregnancies complicated by Rh alloimmunization were included in this study. Middle cerebral artery peak systolic velocity was studied by Doppler ultrasound before and after intrauterine transfusion with adult packed red blood cells (hematocrit = 80-85%). Mean gestational age at time of study was 27 weeks. Paired t-test was used for statistical comparison. A P value of < 0.05 was considered statistically significant. The fetal hematocrit ranged from 5.9% to 30% prior to the procedure, and it was 24.8-53.4%, following the procedure. Mean middle cerebral artery peak systolic velocity was 46.2 +/- 10.7 cm/s prior to the procedure, and it decreased to 31.7 +/- 9.5 cm/s following the procedure (P < 0.01). The increase of fetal hematocrit significantly decreases the middle cerebral artery peak systolic velocity supporting data that this Doppler measurement may be useful for the diagnosis of fetal anemia.

The effect of intraumbilical oxytocin on the third stage of labour

The umbilical vein administration of oxytocin in saline was compared with umbilical vein saline alone and the traditional management of the third stage of labour. Seventy-two women were randomized to 3 groups. Group 1 received intraumbilical 20 IU of oxytocin diluted to 40 mL with saline. Group 2 received intraumbilical vein 40 mL of saline while subjects in group 3 were managed according to the standard protocol without any intraumbilical injection. No significant differences were found in terms of the length of the third stage, the blood loss in the third stage and postpartum haematocrit differences among the 3 groups. The administration of diluted oxytocin or saline do not seem to have any superiority to the traditional management of the third stage of labour.

The concentration of plasma atrial natriuretic peptide in normotensive and preeclamptic pregnancies

Atrial natriuretic peptide (ANP) is a family of peptides secreted by the heart, affecting the cardiovascular, renal and endocrine systems. This study questions previous research findings regarding elevated ANP levels, despite vasoconstriction and hypovolemia, in preeclamptic patients.

MATERIALS AND METHODS

Seventeen patients with preeclampsia, 5 with superimposed preeclampsia with chronic hypertension and 17 normotensive pregnant women were compared with respect to plasma ANP levels. Seventeen non-pregnant women were taken as the control group. All the women, except the ones with superimposed preeclampsia, were age matched and in their third trimester.

RESULTS

ANP levels in the non-pregnant women (6.9 +/- 0.7 pg/ml) were not different from those in the normotensive pregnant women (6.4 +/- 0.7 pg/ml). ANP levels were significantly higher in women with preeclampsia (10.8 +/- 1.8 pg/ml) or superimposed preeclampsia (9.7 +/- 1.4 pg/ml) than in normotensive pregnant women and normal non-pregnant women (P < 0.05). According to the literature, there is a volume depletion in preeclamptic women. However, this wasn't demonstrated in our study group.

CONCLUSION

ANP levels in preeclamptic women were found to be higher than those in normotensive pregnant women. The etiology still remains obscure.

Urinary calcium to creatinine ratio for predicting preeclampsia

Urinary calcium excretion decreases in preeclampsia. To determine the predictability of preeclampsia with hypocalciuria, we investigated the calcium to creatinine ratio and the calcium level of a spot urine sample in 56 primigravid patients aged less than 25 years. Of these 56 cases, 44 remained normotensive and preeclampsia developed in eight cases. There were four cases of gestational hypertension and they are not included in the statistical analysis. The mean age, the mean gestational age at entrance into the study, the mean urine calcium concentration, the mean birthweight, and the mean gestational age at delivery were similar between the normotensive and preeclamptic groups. The mean calcium to creatinine ratio is found to be significantly lower in the preeclamptic group (0.0475 +/- 0.0260) compared with the normotensive group (0.1466 +/- 0.1353; p < 0.0001). A cutoff level of 0.066 for the calcium to creatinine ratio with the use of a receiver operator curve yielded a sensitivity of 75%, a specificity of 86%, and a positive and negative predictive value of 55% and 95%, respectively. The results of this study suggest that a single urine calcium to creatinine ratio might be an effective marker for predicting preeclampsia in a high-risk population.