A case of uterine rupture in mid-trimester spontaneous abortion: a complication of gemeprost vaginal administration

The only prostaglandin analogue licensed in Italy for induction of labour in spontaneous and therapeutic abortion is gemeprost. The authors report a case of spontaneous uterine rupture of a scarred uterus, for previous caesarean sections, in a woman at 20 weeks of gestation with a diagnosis of spontaneous abortion. She received a pessary of gemeprost every three hours. After the fifth pessary, she complained of severe pain. At the ultrasound examination, uterine cavity appeared empty and the dead fetus was dislocated in the abdomen. Emergency laparotomy was performed and uterine tear was repaired. To induce labour for fetal demise or therapeutic abortion in second trimester in women with scarred uterus, the authors decided to lengthen the time between administrations of pessary from four to five hours depending on patient's symptoms. However the appropriate drug regimen has still to be found and more data are necessary.

Matrix array transducer for the examination of fetal heart

The X6-1 xmatrix array transducer allows a completely new approach to the diagnostic ultrasound: it permits visualization of fetal heart in real time, without the need for gating, and it is unaffected by motion artefacts. It is obtained in real time, without any spatial reconstruction. The authors compared this technology with the traditional one in two case reports: a diagnostic doubt of small muscular ventricular septal defect was solved using this new technique; a diagnosis of complete atrioventricular septal defect was confirmed. Three-dimensional real-time imaging would seem very precise in the study of fetal heart: the defects were fully visualized from any angulations. This new technology is promising but from the authors' limited experience, there is no evidence to use it in routine practice. It should be very useful to commence a prospective study on fetuses at risk while testing the superiority of this technique.

Mediastinal masses: a case of fetal teratoma and literature review

Fetal mediastinal masses are rare congenital formations that could complicate pregnancy. They are usually discovered as space occupying lesions in the fetal chest during routine ultrasound scan. The most important prognostic factors of mediastinal masses are mass location, compressing effect causing pulmonary hypoplasia and/or heart failure, and the presence or absence of hydrops. We report a case of fetal mediastinal teratoma and a review of the literature. A 32-year-old woman carrying a fetus with hydrops due to a mediastinal mass underwent cesarean section at 32 1/7 weeks' gestation. A well encapsulated tumor was excised by surgery at one day of life. The baby is now eight months old without respiratory difficulty. To our knowledge, this is the fourth case report of a mediastinal teratoma associated with nonimmune hydrops in a fetus that survived the neonatal period. Fetal mediastinal teratoma requires close surveillance and multidisciplinary management by obstetricians, neonatologists, and pediatric surgeons.

Efficacy of three different antithrombotic regimens on pregnancy outcome in pregnant women affected by recurrent pregnancy loss

INTRODUCTION

Recurrent pregnancy loss (RPL) is a common health problem affecting 1-5% of women at reproductive age.

AIM OF THE STUDY

Evaluation of three different antithrombotic treatments in women with antecedent of RPL, comparing the results in negative and positive to thrombophilic screening pregnant women.

MATERIALS AND METHODS

We recruited 361 women with an antecedent of two or more pregnancy losses. From this group, 167 women became pregnant and considered for the study. The evaluated pregnant women were divided as negative/positive to thrombofilic screening: (a) 80 (48%) with negative thrombophilic screening, (b) 87 (52%) positive to thrombophilic screening. Pregnant women included in the study and considered negative or positive for thrombophilic screening, were randomized into three different therapy groups: (a) group 1: Acetil salicylic acid (ASA) 100 mg daily until third month of pregnancy, (b) group 2: low molecular-weight heparin (LMWH) - enoxaparine 40 mg daily until third month of pregnancy, (c) group 3: ASA 100 mg plus LMWH 40 mg daily until third month of pregnancy.

RESULTS

In 80 negative to thrombophilic screening pregnant women, the comparison of efficacy of the three treatments, shows that all three treatment regimens were significantly effective comparing live births against fetal losses. In 87 positive to thrombophilic screening pregnant women, the comparison of efficacy for the three regimens, shows that the therapy with LMWH or LMWH plus ASA are significantly protective against fetal losses with respect to ASA, which showed a high number of fetal losses (11 live births, 18 fetal losses).

COMMENT

We suggest that thromboprophylaxis is indicated in women with RPL independently from positiveness to thrombophilic markers.

Nuchal translucency as a predictor of adverse pregnancy outcome

BACKGROUND

Thickened nuchal translucency (NT) has been related to fetal genetic syndromes, structural abnormalities, and other diseases. The aim of this research was to evaluate the association of NT with adverse pregnancy outcomes.

STUDY DESIGN

In the period 2002-2004 in 2104 pregnant women between 10+6 and 13+5 weeks' gestation, NT was evaluated as a parameter for aneuploidy screening: out of these, 734 singleton pregnant women that underwent 2nd trimester amniocentesis and whose pregnancy outcome were known were selected. NT was statistically correlated to pregnancy and neonatal outcome.

RESULTS

Median gestational age (GA) at NT evaluation was 11+2 weeks' gestation. NT median was 1.1 mm (0.9-1.4 mm, 25th-75th centile, range 0.5-4.0 mm). After multiple logistic regressions, the variables significantly associated to NT values were: threatened preterm labor (p<0.008) and preterm labor (p<0.02). The best diagnostic accuracy point was NT>95th centile and >1.5 MoM for the prediction of threatened preterm labor.

CONCLUSION

In this series, increased NT values were associated to threatened preterm labor and preterm labor in euploid fetuses: this finding may have clinical consequences in the management of such pregnancies.

Improvement of uterine artery Doppler velocimetry indices after metroplasty in arcuate uteri

OBJECTIVE

Our study aimed to evaluate the effect of metroplasty performed in arcuate uteri on uterine artery Doppler velocimetry.

STUDY DESIGN

We performed uterine artery Doppler velocimetry transvaginally before and after metroplasty in 36 women with arcuate uteri. Pulsatility indexes (PI) of uterine arteries were calculated and the presence or absence of a protodiastolic notch was evaluated.

RESULTS

Comparing Doppler indexes before and after metroplasty, we found that uterine artery impedance improves as assessed by lower mean PI. We observed that PI after intervention was significantly lower compared with indexes before for mean Doppler index evaluations (mean uterine PI pre: 2.07+/-0.61 and post: 1.49+/-0.24 [p<0.03]). No differences were observed as regards bilateral protodiastolic notch absence or presence. A protodiastolic notch was present in 22 out of 36 women before metroplasty (61%), and a notch was observed in 19 out of 36 (52%) after metroplasty.

CONCLUSIONS

Our results suggest that, metroplasty, as well as making the uterine cavity wider, leads to better uterine perfusion.

Severe hypoplasia of the right femur, ipsilateral agenesia of the fibula and twisted right foot in a 24-week-old fetus with proximal femoral focal deficiency (PFFD)

A case of a 24-week-old fetus of non consanguineous parents with an ultrasonographic diagnosis of a short right femur, ipsilateral agenesia of the fibula and a twisted right foot is described. Cordocentesis revealed a normal 46XY karyotype. The parents were informed on treatment options and after psychological counselling they decided to undergo an abortion. Post mortem examination confirmed the diagnosis of a severe right limb malformation.

Ultrasonographic patterns of fetal breathing movements in normal pregnancy

OBJECTIVE

To assess through pregnancy fetal breathing movements (FBMs) patterns detected by M-mode and Doppler velocimetry technology.

METHODS

In this cross-sectional study FBMs were investigated in 1882 uncomplicated pregnancies over a 4-year period. Abdominal and thoracic wall movements of fetuses between 14 and 40 weeks of gestation were studied by M-Mode scan, and color Doppler velocimetry with spectral imaging analysis was used to investigate the presence of FBMs associated with nasal fluid flow velocity waveforms (NFFVWs).

RESULTS

Abdominal movements were observed in 19% of cases when gestation was less than 20 weeks and in 61% of cases when it was between 21 and 25 weeks; chest movements were significant after 21 weeks; and NFFVWs were detected at 22 weeks and increased progressively to 93% of cases at term.

CONCLUSIONS

Fetal breathing movements are a complex phenomenon with a composite, progressive pattern of development during gestation.

Three-dimensional sonography and hysterosalpingosonography in the diagnosis of uterine anomalies

Uterine anomalies implicated in female subfertility, implantation failure and miscarriages can often be detected often by two-dimensional transvaginal (2D TV) ultrasound scanning. When used as a screening test TV ultrasound has provided sensitivity rates of up to 100% about uterine anomalies. Improved depiction has been achieved with the development of hysterosalpingosonography (HSSG). The anechoic interface provided by the saline solution allows the examiner to determine whether an abnormality is intracavitary, endometrial, or submucosal. The aim of this study was to evaluate the role of 2D TV contrast sonography and 3D TV ultrasound in the diagnosis of congenital uterine anomalies in comparison with their appearance of hysterosalpingosonography findings.

[Therapy or prevention of fetal infection by cytomegalovirus with immunoglobulin infusion in pregnant women with primary infection]

OBJECTIVE

Administration of cytomegalovirus (CMV)-specific immunoglobulins to pregnant women with primary CMV infection in order to inhibit viral activity.

MATERIALS AND METHODS

We considered 2 groups of patients including 24 pregnant women.

GROUP A

12 women with primary maternal-fetal CMV infection, shown by CMV culture and CMV DNA detection in 9 (75%) and by only CMV DNA detection in 3 (25%) of the amniotic fluid (AF) samples. These pregnant women were treated with infusions of CMV-specific immunoglobulins (200 U/Kg of maternal weight and 400 U/Kg of fetal weight to prevent CMV pneumonia and gastroenteritis). As control group we considered 15 pregnant women, 5 of whom had CMV-positive AF samples demonstrated by polymerase chain reaction (PCR) and 10 also by CMV culture.

GROUP B

12 women with primary CMV infection, who were treated with monthly infusions of specific immunoglobulins to prevent the transmission of CMV to the fetus. In the control group we followed up 53 patients who were not treated, including 15 subjects with CMV-positive AF samples, 20 with CMV-negative AF samples and 18 women who did not accept amniocentesis.

RESULTS

GROUP A

All 9 neonates born to mothers with culture and DNA positive AF samples were CMV infected. On the contrary, the babies born to 3 women with only PCR-positive amniotic fluid were CMV-negative by culture and DNA detection. Of 9 neonates infected, 8 were asymptomatic and 3 became culture-negative before they were one year old. The only symptomatic baby (IUGR and ventriculomegaly diagnosed by ultrasound during the pregnancy) was treated with ganciclovir and foscarnet. Of 15 non-treated patients, 11 had ultrasound signs of placental and/or fetal CMV involvement. Seven of these (46%) aborted and 4 (27%) delivered neonates with severe symptomatic infection. The other 4 patients delivered oligo-symptomatic CMV infected neonates positive by culture or PCR only. Overall, the prevalence of symptomatically infected neonates or fetuses was significantly higher (p = 0.02) among non-treated than treated women. Moreover, the babies of treated women showed less prolonged (p = 0.01) viruria than those of non-treated patients.

GROUP B

all 11 pregnant women, treated with immunoglobulins delivered CMV-negative neonates. One patient, who had interrupted infusions at the 24th gestation week, delivered an asymptomatic CMV infected baby. In the control group, 4 women with CMV-negative AF samples delivered neonates with asymptomatic infection. Of 18 patients who did not undergo amniocentesis, 9 (50%) aborted; of remaining 9 women, 3 (33%) delivered CMV infected neonates.

CONCLUSIONS

Our data suggest that CMV immunoglobulins may be effective for treatment or prevention of fetal CMV infection.

Effect of antenatal betamethasone therapy on maternal-fetal Doppler velocimetry

BACKGROUND

The effect of antenatal betamethasone on fetal parameters includes a transient reduction of FHR variation and of fetal body movements. An effect on maternal-fetal blood flow has also been shown, with non-univocal results.

AIMS

To evaluate the effect of antenatal betamethasone in third trimester singleton high-risk pregnancies by Doppler technology.

SUBJECTS AND METHODS

Thirty-six pregnant women who received a full course of betamethasone (12 mg i.m. two times, 24 h apart) were studied. The Doppler examination included the assessment of the pulsatility index (PI) of the umbilical artery (UA PI), the middle cerebral artery (MCA PI) and of resistance index of uterine arteries (Ut RI) before treatment, and 48 and 96 h after second dose of betamethasone.

RESULTS

No significant variation was noted in UA PI through betamethasone therapy. MCA PI decreased significantly 48 h from the last injection of betamethasone (P=0.002), and returned to basal values at 96 h. No difference was found for the other Doppler parameters examined. When serial Doppler studies were analyzed according to the gestational age, in the group <32 weeks' gestation, MCA PI decreased significantly after 48 h (P<0.006) and returned to pre-treatment values after 96 h from the last betamethasone dose. Conversely, no difference was found in Doppler serial measurements in any of the analyzed districts in the subgroup > or =32 weeks.

CONCLUSION

Betamethasone treatment is associated with a significant, although transient, reduction of MCA PI, especially at gestational ages <32 weeks'.

Acute effects of 3,4-methylenedioxymethamphetamine alone and in combination with ethanol on the immune system in humans

Cell-mediated immune response and release of cytokines after the administration of 3,4-methylenedioxymethamphetamine (MDMA, "ecstasy") alone and in combination with ethanol were assessed in a double blind, randomized, crossover, controlled clinical trial. Six healthy male recreational users of MDMA participated in four different experimental sessions, with a washout interval between sessions of 1 week, in which single oral doses of MDMA (100 mg), ethanol (0.8 g/kg), the combination of both drugs, and placebo were tested. Acute MDMA administration produced a time-dependent immune dysfunction in association with serum concentrations of the drug as well as cortisol stimulation kinetics. Although total leukocyte count remained unchanged, there was a decrease in the CD4 T/CD8 T-cell ratio due to a decrease in both the percentage and absolute number of CD4 T-helper cells and simultaneous increase in natural killer (NK) cells. Ethanol consumption produced a decrease in T-helper cells and B lymphocytes. The combination of MDMA and ethanol caused the highest suppressive effect on CD4 T cells and increasing effect in NK cells. Drugs treatment produced a high increase of immunosuppressive cytokines (transforming growth factor-beta and interleukin-10) and a switch from Th1-type cytokines (interleukin-2 and interferon-gamma) to Th2-type cytokines (interleukin-4 and interleukin-10). Disregulation in the production of pro- and anti-inflammatory cytokines with an unbalance toward anti-inflammatory response was also observed. The immune function shows a trend toward baseline levels at 24 h after MDMA kinetics. This transient defect in immunological homeostasis, if temporarily repeated, might alter the immune response with a risk for the general health status.

The effects of fetal breathing movements on the utero-fetal-placental circulation

Important factors which may affect the fetal circulation are the fetal breathing movements (FBMs) and other movements adn the features of fetal circulation. Recent studies have demonstrated that FBMs are a normal phenomenon of intrauterine development and that there are two patterns of FBMs: (1) A predominant pattern of rapid, irregular (in rate and amplitude) episodic movements, with interspersed episodes of apnea that is present more than 50 percent of the time and accounts for more than 90 percent of the breathing activity. Interestingly, periodic sighs are often seen during these FBMs; (2) There is also a less frequent pattern of sporadic, slow (1 to 4 movements/min), deep inspiratory movements, like sighs or gasps, or espiratory efforts which resemble grunting, coughing, or panting. The first pattern, which represents normal fetal respiratory activity, only occurs during rapid eye movements (REM) sleep, and it is unrelated to changes in blood gases and pH values and to afferent impulses from aortic and carotid bodies; FBMs may produce intrathoracic pressure swings of 35 Torr or more and are independent of Hering-Breuer reflexes. This pattern is usually accompanied by increased FHR beat-to-beat variability and increased systolic and diastolic blood pressure and flow (BF). Therefore, they may influence the velocimetry of B.F. in humans, e.g., RED and ARED in the umbilical artery blood flow (UABF), which do not necessarily indicate impending fetal demise. The second pattern is unrelated to the fetal behavioral state and blood gas tensions. Concerning the effects of drugs on FBMs, we have analysed the effects aminophylline (A)(bolus of 240 mg followed by 0.2 mg/kg/min) given to women not in labor; A caused a prompt and sustained FBMs that started as vorteces and then as regular inspiratory and expiratory movements, which increased in frequency (up to 88/min) and depth. Hexoprenaline given to pregnant women with threatened preterm labor were able to elicit FBMs and NFFV; the infusion of 0.3 microg/min increased UABF. Conjugated estrogens administered to the mother as a 10 mg bolus enhanced FBMs, as documented by TM and nasal flow velocity waveforms (NFFV); this was associated with an increased UABF; betamethasone (4 mg bolus to the mother) was shown to induce FBMs and an increased UABF. In a twin pregnancy betamethasone (0.5 mg/kg) was administered IV into the umbilical vein in one fetus and IM to the other; in both cases bradycardia and increase in UABF occurred, immediately after IV infusion, and after 30 min following IM injection FBMs were induced or enhanced in frequency and depth. The flow in MCA was unchanged. In conclusion, the fetal circulation is influenced by fetal behavioural states, particularly by FBMs that affect the fetal cardiovascular function, including blood pressure and FHR thereby conditioning the velocimetric response of its major vessels, i.e., UA and MCA BF, whose alterations do not necessarily reflect impending fetal demise.

Transvaginal sonographic evaluation of endometrial polyps: a comparison with two dimensional and three dimensional contrast sonography

Endometrial polyps are a frequent cause of menorrhagia and are often associated with infertility. Routine transvaginal (TV) ultrasound evaluation may detect intrauterine anomalies. Sonographic evaluation of the endometrium after uterine cavity distention, called hystero-sono-salpingography (HSSG), improves the resolutive effectiveness of TV sonography. Recently the development of three-dimensional (3D) scanning of the uterine cavity has provided accurate images. The purpose of this study was to compare conventional 2D and 3D scanning of the uterine cavity with or without saline contrast medium in the detection and evaluation of focal endometrial polyps. Twenty-three patients out of 642 women suggestive for intrauterine anomalies at routine TV sonogram were examined by 2D and 3D sonography before and after intrauterine saline contrast medium. Sonographic appearance was verified by hysteroscopic and histologic evaluation. Two-dimensional TV sonography diagnosed 23 polyps versus 16 confirmed at hysteroscopic and histologic examinations, revealing a specificity of 69.5%; 2D TV HSSG diagnosed 17 polyps, with a specificity of 94.1%; 3D TV sonography diagnosed 18 polyps, with a specificity of 88.8%; 3D HSSG diagnosed 16 polyps according to hysteroscopic and histologic findings, with a specificity of 100%. HSSG has been demonstrated to be an effective and suitable method in the detection of intrauterine anomalies, particularly with 3D sonography.

Prenatal diagnosis of fetal cytomegalovirus infection after primary or recurrent maternal infection

OBJECTIVE

To determine the reliability of prenatal diagnosis of cytomegalovirus infection in women with primary or recurrent infection.

METHODS

Amniotic fluid (AF) samples from 117 pregnant women were evaluated for cytomegalovirus culture and cytomegalovirus-DNA detection. Neonatal and postnatal samples also were examined to confirm or exclude transmission of maternal-fetal cytomegalovirus infection.

RESULTS

Of 25 women with primary cytomegalovirus infection, 13 (52%) had cytomegalovirus-positive AF samples by polymerase chain reaction (PCR), nine of which also were diagnosed by culture. All eight neonates born to mothers whose AF was cytomegalovirus-positive by PCR and culture were cytomegalovirus infected, and three were symptomatic. One aborted fetus had cytomegalovirus-DNAemia. Of four women with cytomegalovirus-positive AF samples by PCR only, two delivered asymptomatic cytomegalovirus-infected neonates and two aborted (one fetus had cytomegalovirus encephalopathy). Of 45 mothers with recurrent infection, two with AF cytomegalovirus-positive by PCR and culture, and another with cytomegalovirus-positive AF samples by PCR only, aborted cytomegalovirus-DNA-positive fetuses. Of the other seven women with cytomegalovirus-positive AF samples by PCR only, two delivered asymptomatic cytomegalovirus-infected neonates, two delivered neonates cytomegalovirus-positive by PCR only (one was symptomatic), and three delivered infants cytomegalovirus-negative by PCR and culture. All 47 mothers with nonactive cytomegalovirus infection and cytomegalovirus-negative AF samples had uninfected neonates. Polymerase chain reaction was superior to viral culture in sensitivity and negative predictive value (100% compared with 57% and 94%, respectively) but was lower in specificity and positive predictive value (97% and 83%, respectively, compared with 100%).

CONCLUSION

Prenatal diagnosis of fetal cytomegalovirus infection should include PCR in addition to viral culture, particularly for congenital cytomegalovirus infections following maternal recurrence.

Multi-system cytomegalovirus fetopathy by recurrent infection in a pregnant woman with hepatitis B

A pregnant woman with acute hepatitis B virus (HBV) infection had her second pregnancy terminated at 25 weeks' gestation because of fetal ascites and ventriculitis. Meconium peritonitis was also found at autopsy. No HBV DNA but cytomegalovirus (CMV) DNA was detected in the fetal liver and ascitic fluid. Recurrent maternal CMV infection was demonstrated by pre-existing CMV IgG antibodies, high IgG avidity and low IgM levels. After abortion, the patient developed chronic active hepatitis. Nevertheless, having become pregnant again with a new partner, she had an uneventful third pregnancy and gave birth to a healthy boy.

Hyperimmunoglobulin therapy for a twin fetus with cytomegalovirus infection and growth restriction

OBJECTIVE

Cytomegalovirus immunoglobulin was administered to a pregnant woman with primary cytomegalovirus infection and placental involvement of 1 twin fetus, in whom growth restriction had developed.

STUDY DESIGN

Inhibition of viral activity was attempted by administration of high-titer cytomegalovirus neutralizing antibodies for therapy of the involved fetoplacental unit and prevention of cytomegalovirus infection in the uninfected twin fetus.

RESULTS

After cytomegalovirus immunoglobulin infusions the placental edema decreased and the infected fetus started to grow once again, showing at birth only hepatosplenomegaly associated with viruria and cytomegalovirus deoxyribonucleic acidemia. Moreover, cytomegalovirus immunoglobulin G avidity increased and cell-mediated immunity improved. The other twin, who had negative results of cytomegalovirus culture and deoxyribonucleic acid detection at birth, was found to have cytomegalovirus deoxyribonucleic acid in the urine after 1 week. From the age of 9 months, however, both twins had persistent negative results of cytomegalovirus deoxyribonucleic acid detection.

CONCLUSION

Although large-scale studies are needed to establish the real efficacy and the best therapeutic regimen, cytomegalovirus immunoglobulin may be considered for treatment or prevention of fetal cytomegalovirus infection.

Feasibility and safety of a new technique of extracorporeal photochemotherapy: experience of 240 procedures

BACKGROUND AND OBJECTIVE

Extracorporeal photochemotherapy (ECP) is a therapeutic approach based on the biological effects of ultraviolet light (UV) - A and psoralens on mononuclear cells collected by apheresis. Recently, ECP has been under investigation as an alternative treatment for various immune and autoimmune diseases. The aim of this study was to evaluate the safety and feasibility of a new three-step ECP technique, in terms of reproducibility, acceptance, tolerability, and short and long term side effects.

DESIGN AND METHODS

Seventeen patients affected by acute or chronic graft-versus-host disease (GvHD), pemphigus vulgaris, or interferon-resistant chronic hepatitis C and one patient being treated for prevention of heart transplant rejection underwent 240 ECP procedures. MNC collection and processing parameters were recorded, biological effects of UV-A/8 methoxy-psoralen (8-MOP) were evaluated, and short and long term side effects were monitored.

RESULTS

At a mean follow up of 7 months (range 2-19) 240 ECP had been completed, a mean of 7,136 mL (range 1,998-10,591) of whole blood having beenprocessed per procedure. The mean of total nucleated cells collected per procedure was 6.5x109 (range 0.65-23.8), with a mean MNC percentage of 85% (41. 4-98%) in a mean final volume of 115.5 mL (37-160). No severe side effects were documented and no infectious episodes occurred throughout the course of the treatment.

INTERPRETATION AND CONCLUSIONS

The new ECP technique was highly reproducible as regards the collection and each processing step. Short and long term side effects were mild. No increase in infectious episodes was recorded. All patients willingly underwent ECP, demonstrating an excellent tolerability for the procedure even after several courses.

Pregnancy-associated breast cancer

Pregnancy-associated breast cancer, which is defined as all breast cancer diagnosed during pregnancy or within the following year, is a relatively rare finding. Due to the particular difficulties in the diagnosis of breast cancer during this period, pregnant women tend to present more advanced disease at diagnosis. Four cases of pregnancy-associated breast cancer referred to our Institute are described as a contribution to the knowledge of this disease.

Ovarian blood flow before and after conservative laparoscopic treatment for endometrioma

To evaluate the vascular changes in ovaries affected by endometriomas 28 women with ovarian endometriosis underwent transvaginal ultrasound with color flow imaging and blood flow analysis of the ovarian artery before and after laparoscopic conservative treatment of the ovarian cyst. Mean pulsatility index (P.I.) and resistance index (R.I.) of the ovarian artery on the side affected by endometrioma were compared using Student's t-test. Mean P.I. after laparoscopy (1.59) was significantly lower (p = 0.001) than before surgical intervention (2.17). Analogously the mean R.I. was significantly different (p = 0.001) when compared before (0.81) and after (0.73) laparoscopy. Color Doppler velocimetry may add greater understanding of the ovarian hemodynamic changes that occur after conservative surgery on the ovary.

Diabetes and pregnancy: prophylaxis of genital infections

Diabetic pregnant women have many potential reasons to have genital infections such as poor metabolic control and impairement of leucocyte function. Relative immune deficiency exists in pregnancy. This study was designed to test the hypotheses that pregnant patients with insulin-dependent diabetes have a higher rate of ante partum genital infections when compared with a pair-matched control population. Two groups of pregnant women consisting of 23 patients with and 23 without diabetes mellitus, underwent colposcopy and cytology between 16th and 24th week of gestation to detect the presence of human papilloma virus (HPV), Gardnerella vaginalis, Candida albicans and aspecific infections. No significant differences were observed between the two groups.

Unusual case of caudal duplication (dipygus)

We report the case of a dipygus diagnosed by sonography in the second trimester that had 6 lower extremities, double external male genitalia, a megabladder, 3 dilated ureters, and a polycystic right and a pelvic left kidney. This complex malformation represents a rare type of caudal duplication.

Amniotic fluid nitric oxide and uteroplacental blood flow in pregnancy complicated by intrauterine growth retardation

OBJECTIVE

To examine the correlation between placental nitric oxide production and uteroplacental blood flow.

PARTICIPANTS

Thirty-one pregnant women with fetuses with intrauterine growth retardation and 27 normal pregnancies as controls.

DESIGN

Correlation between amniotic fluid measurements of nitrite metabolite in the third trimester and flow velocimetry waveforms recorded from uterine, umbilical and fetal middle cerebral arteries. Intrauterine growth retarded pregnancies were compared with controls.

MAIN OUTCOME MEASURES

Concentrations of nitric oxide metabolites (NO2- and NO3-) in amniotic fluid were correlated with flow velocimetry waveforms findings by the determination of correlation coefficient.

RESULTS

Overall median nitrite values in amniotic fluid were higher (P < 0.01) in intrauterine growth retarded patients (median 8.6 micromol/mg creatinine) than in controls (5.6 micromol/mg creatinine). Pathologic uterine flow velocimetry waveforms in uterine artery (-2SD) were observed in 12 women of the intrauterine growth retarded group, and the concentration of amniotic fluid nitrite was significantly lower (P < 0.01) in these patients (median 4.45 micromol/mg creatinine) than in those with normal flow velocity waveforms (median 11.43 micromol/mg creatinine). A significant negative correlation was observed between nitrite concentrations and uterine artery resistance index, umbilical artery pulsatility index and umbilical artery pulsatility index:middle cerebral artery pulsatility index ratio.

CONCLUSIONS

We conclude that placental nitric oxide is significantly associated with uteroplacental blood flow and may be important in maintaining adequate uteroplacental perfusion in intrauterine growth retarded pregnancies.

Intraamniotic surfactant for prevention of neonatal respiratory distress syndrome (IRDS): rationale and personal experience

OBJECTIVE

To evaluate the efficacy of intramniotic instillation of supplementary surfactant for the prophylaxis of neonatal IRDS in an emergency obstetric setting.

STUDY DESIGN

Supplementary natural surfactant (SS) was administered intra-amniotically (80 mg in 1 ml) under ultrasound guidance in the proximity of the fetal nostrils and mouth in six pregnant women at 24-32 weeks gestation, with immature amniotic fluid indices of fetal lung maturity, and whose delivery was imminent because of severe fetal distress, deteriorating maternal conditions, or refractory vaginal bleeding. The administration of SS was preceded by IV aminophylline to the mother (a bolus of 240 mg over 10 min, and a maintenance dose of 0.02-0.1 mg kg-1 min-1) in order to elicit sustained fetal breathing movements.

RESULTS

The clinical conditions of the six newborn infants were good with no respiratory problems in four cases, and with mild IRDS in the remaining two, which, however, resolved uneventfully.

CONCLUSIONS

It is suggested that this prophylactic approach has a great potential for becoming a reliable option for the antenatal prevention of IRDS.

Surfactant administration to the human fetus in utero: a new approach to prevention of neonatal respiratory distress syndrome (RDS)

Supplementary surfactant (80 mg in 1 ml) was administered intra-amniotically in proximity of the fetal mouth to 4 preterm fetuses (28 to 32 wks) with immature amniotic fluid indexes and whose delivery was imminent. Administration was preceded by a aminophylline infusion (loading dose of 240 mg and maintenance of 0.8 mg/kg/min) to the mother in order to elicit sustained fetal breathing movements. Following delivery by cesarean section, the absence of signs of respiratory distress in the infants along with a completely uneventful clinical course suggests that the present therapeutic approach has great potential for becoming a reliable option for the antenatal prevention of RDS.

Reference blood values of iron metabolism in cynomolgus macaques

Iron deficiency anemia is a human health problem of global significance, particularly as it affects pregnant women and infants. While the study of nonhuman primates has resulted in valuable knowledge about iron metabolism, hematologic and biochemical reference ranges for the parameters of iron metabolism are difficult to document in healthy monkeys. At our institution, we maintain a large breeding colony of healthy cynomolgus monkeys (Macaca fascicularis). Data compiled after sampling nonpregnant females and male members of this colony are presented as reference ranges for red cell number, hemoglobin, hematocrit, mean cellular volume, mean cellular hemoglobin, mean cellular hemoglobin concentration, serum iron, total iron-binding capacity, serum transferrin, and serum ferritin.

Relationship between ultrasound findings in pregnancy and neonatal morbidity

In 142 diabetic pregnancies fetal biparietal diameter (BPD), transverse abdominal diameter (TAD) and abdominal circumference (AC) were estimated by means of serial ultrasound examinations. An accurate evaluation of fetal growth was obtained in 85% of the cases. AC was found to have the highest degree of reliability in predicting macrosomia (71%) followed by TAD (60%) and BPD (17%). Placental morphology was estimated at the last scanning before delivery in 85 of the patients. In pregnancies resulting in macrosomic infants the placental maturation seemed to be retarded. In 26 patients a third trimester amniocentesis was performed. A mature (grade III) placenta was always associated with a lecithin-sphingomyelin (L/S) ratio greater than 2, indicating fetal lung maturity but there was no constant relation between placental maturity and the L/S ratio. In conclusion, ultrasound examination during diabetic pregnancy offers valuable information concerning the prenatal diagnosis of macrosomia and could serve as a guidance in the determination of the optimal time and route of delivery. The grading of placental maturity might help to identify fetuses at risk, but further studies in this area are needed before final conclusions can be drawn.

Education, training creates effective board of trustees

The problems facing today's hospitals are not new - except in magnitude. To keep our institutions funded, the selection of the trustee development committee should receive the first priority of the board, according to this author.