Changes in pediatric psychiatric emergency during the coronavirus disease 2019 pandemic

Purpose@#The lifestyle changes during the coronavirus disease 2019 pandemic possibly affected mental health among the pediatric population. We aimed to analyze changes in psychiatric emergency-related visits to the emergency department (ED). @*Methods@#We reviewed cases of pediatric patients (≤ 18 years) who visited the ED of a tertiary hospital with psychiatric emergency as a chief complaint from March 2019 through February 2021. The study period was dichotomized by March 2020, starting point of social distancing, into the pandemic and control periods. Clinical data were collected and compared between the 2 periods. @*Results@#A total of 246 cases with a mean age of 15.2 years were included. The overall visits to the ED decreased to 43.8% whereas the proportion of psychiatric emergency-related visits increased during the pandemic period, compared to the control period (0.5% vs. 1.0%; P < 0.001). The cases with suicidality, including ideation and attempt, increased in both number and proportion during the pandemic period (51 [38.9%] vs. 63 [54.8%]; P = 0.013). @*Conclusion@#Pediatric psychiatric emergency-related visits, particularly suicidality, proportionally increased during the pandemic. This finding may be useful to prepare psychiatric resources in EDs.

Risk factors for acute bronchiolitis-related return visits to the emergency department

Purpose@#Acute bronchiolitis (AB)-related return visits incur overuse of emergency medicine resources, crowding of emergency departments (EDs), and deterioration of rapport with the guardians. The authors aimed to analyze factors associated with the return visits to the ED. @*Methods@#This study was conducted based on the medical records of 447 children aged 24 months or younger with AB who visited the ED from January 2019 through December 2020. A return visit was defined as an AB-related visit to the ED within 7 days of index visit. According to the return visit, we compared the clinical features. Multivariable logistic regression was conducted to identify independent factors for the return visit. @*Results@#Of the 323 children with AB, 77 (23.8%) made return visits. The returning children showed a younger median age (6 [interquartile range, 2-10] vs. 8 months [3-14]; P < 0.001), a lower mean oxyhemoglobin saturation (92.9 ± 4.3% vs. 97.1 ± 1.8%; P < 0.001), and higher frequencies of congenital heart diseases (22.1% vs. 10.6%; P = 0.009) and bronchopulmonary dysplasia (11.7% vs. 5.7%; P = 0.013), and respiratory syncytial virus infection (57.1% vs. 37.0%; P = 0.002). No other variables, such as the hospitalization rate, differed as per return visits. The factors associated with return visits were respiratory syncytial virus infection (adjusted odds ratio, 9.41; 95% confidence interval, 2.13-41.57), lower oxygen saturation (2.00; 1.64-2.43), and age younger than 3 months (1.25; 1.07-1.24). @*Conclusion@#AB-related return visits may be associated with age younger than 3 months, lower oxygen saturation, and respiratory syncytial virus infection.

Pediatric Sedation in the Emergency Department: Trends from a Nationwide Population-based Study in Korea, 2007–2018

Background@#Pediatric sedation in the emergency department (ED) is widely performed in Korea; thus exploring the trends of its use is necessary. This study aimed to investigate the characteristics of patients and sedatives use in the ED and verify their changes over recent years. @*Methods@#A nationwide population-based retrospective study was conducted including pediatric patients aged ≤ 15 years who received sedative medication in the ED and were discharged during 2007–2018, using the Korean Health Insurance Review and Assessment Service database. Patient characteristics (age, sex, level of ED, and diagnosis) and type of sedative used were analyzed. @*Results@#Sedation was performed in total 468,221 visits during 2007–2018 (399,320 visits, at least 3.8% of overall ED visits during 2009–2018). Among these, 71.0% were children aged 1–3 years and 93.5% were sedated to support diagnosis of injury. An increase in total sedation was observed in patients aged 4–6 years during the study period (from 13.8% to 21.8%). A gradual decrease in the use of chloral hydrate (CH) compared with an increase in ketamine use was observed (CH, from 70.6% to 28.6%; ketamine, from 23.8% to 60.7%). Therefore, ketamine was the most used sedative since 2014. The most frequently used sedatives over the study period differed according to age groups (CH in <1 year and 1–3 years; ketamine in 4–6 years and 7–10 years; and midazolam in 11–15 years). @*Conclusions@#The characteristics of patients related to sedatives use in the ED have changed over time. These changes should be considered in the development of future Korean guidelines regarding pediatric sedation in the ED.

Pediatric Sedation in the Emergency Department: Trends from a Nationwide Population-based Study in Korea, 2007–2018

Background@#Pediatric sedation in the emergency department (ED) is widely performed in Korea; thus exploring the trends of its use is necessary. This study aimed to investigate the characteristics of patients and sedatives use in the ED and verify their changes over recent years. @*Methods@#A nationwide population-based retrospective study was conducted including pediatric patients aged ≤ 15 years who received sedative medication in the ED and were discharged during 2007–2018, using the Korean Health Insurance Review and Assessment Service database. Patient characteristics (age, sex, level of ED, and diagnosis) and type of sedative used were analyzed. @*Results@#Sedation was performed in total 468,221 visits during 2007–2018 (399,320 visits, at least 3.8% of overall ED visits during 2009–2018). Among these, 71.0% were children aged 1–3 years and 93.5% were sedated to support diagnosis of injury. An increase in total sedation was observed in patients aged 4–6 years during the study period (from 13.8% to 21.8%). A gradual decrease in the use of chloral hydrate (CH) compared with an increase in ketamine use was observed (CH, from 70.6% to 28.6%; ketamine, from 23.8% to 60.7%). Therefore, ketamine was the most used sedative since 2014. The most frequently used sedatives over the study period differed according to age groups (CH in <1 year and 1–3 years; ketamine in 4–6 years and 7–10 years; and midazolam in 11–15 years). @*Conclusions@#The characteristics of patients related to sedatives use in the ED have changed over time. These changes should be considered in the development of future Korean guidelines regarding pediatric sedation in the ED.

Clinical Implications of Ketosis in Children with Benign Convulsions with Mild Gastroenteritis

Age group characteristics of clinical features and use of epinephrine in children with anaphylaxis who visited the emergency department

PURPOSE: Diagnosis of anaphylaxis depends on clinical manifestations and a high index of suspicion, and a misdiagnosis can lead to a preventable death. We aimed to investigate age group characteristics of clinical features and epinephrine use in children with anaphylaxis who visited the emergency department (ED).METHODS: We performed a retrospective chart review of 138 children who visited a tertiary care hospital ED from January through December 2018, and were discharged with anaphylaxis as the diagnosis. Anaphylaxis was defined according to the National Institutes of Allergy and Infectious Disease criteria. The children were divided into 4 age groups; infants (< 1 year), preschoolers (1–5 years), schoolers (6–11 years), and adolescents (12–18 years). Clinical features and epinephrine use were compared among the age groups.RESULTS: Of the 138 children with presumed anaphylaxis, 108 met the criteria. The most common cause was food (74%), followed by drugs (10.2%). Epinephrine was used in 82 children (75.9%). The infants and preschoolers reported less frequent cardiovascular symptoms (0%–3.6% vs. 26.5%, P = 0.020) and epinephrine use (33.3%–70.9% vs. 91.2%, P = 0.037) compared to the adolescents. The former 2 age groups reported food as triggers more frequent, and often reported food-associated and respiratory or gastrointestinal symptoms.CONCLUSION: Infants and preschoolers with anaphylaxis may undergo less frequent cardiovascular symptoms and epinephrine use compared to adolescents. This feature prompts to increased epinephrine use in the former age groups even without ageadjusted hypotension.

Characteristics of orbital wall fractures in preschool and school-aged children

OBJECTIVE: This study aimed to evaluate the injury patterns in pediatric patients with an orbital wall fracture (OWF) and to identify the differences in injury patterns between preschool and school-aged patients with OWF who presented to the emergency department. METHODS: We performed a retrospective observational study in the emergency department of a tertiary hospital between January 2004 and March 2014. A total of 177 pediatric patients (7 years) pediatric groups. RESULTS: The inferior wall was the most common fracture site in both the preschool and school-aged pediatric groups (50.0% vs. 64.4%, P=0.15). The male-to-female ratio and the mechanism of injury showed significant differences between the two age groups. Violence was the most common mechanism of injury in the school-aged pediatric group (49.3%), whereas falls from a height caused OWF in approximately half of the patients in the preschool pediatric group (42.9%). Concomitant injuries and facial fractures had a tendency to occur more frequently in the school-aged pediatric group. CONCLUSION: Significant differences according to the sex and mechanisms of injury were identified in preschool and school-aged pediatric patients with OWF.

Point-of-care ultrasound may reduce emergency department length of stay in children with nonspecific manifestations of intussusception

PURPOSE: To investigate whether performance of point-of-care ultrasound (POCUS) can reduce emergency department length of stay (EDLOS) for children with nonspecific manifestations of intussusception (NMI), defined as 2 or less manifestations of the classic triad of intussusception, and/or vomiting. METHODS: We reviewed medical records of 141 consecutive children with intussusception aged 6 years or younger who visited the emergency department of Asan Medical Center in Seoul, Korea from May 2014 through April 2016 and underwent diagnostic radiology ultrasound and pneumatic reduction. The children were grouped according to whether they underwent POCUS or not (POCUS and no POCUS groups, respectively). POCUS was performed to children with NMI by an attending emergency physician who had completed a POCUS training course endorsed by the Korean Society of Pediatric Emergency Medicine. We measured EDLOS, which consisted of door-to-reduction and observation times. These time intervals were compared between the 2 groups. RESULTS: Of 112 eligible children, 65 (58%) underwent POCUS. The median EDLOS was shorter in the POCUS group than in the no POCUS group (566 minutes, interquartile range [IQR] 497 to 765 vs. 745 minutes, IQR 551 to 981; P = 0.003). The median door-to-reduction and observation times were also shorter in the POCUS group (105 vs. 138 minutes, P < 0.001 and 440 vs. 628 minutes, P = 0.008, respectively). These differences were possibly due to the performance of POCUS and the trend toward early discharge after pneumatic reduction. We found 1 child with false negative result on POCUS, but there may have been more. CONCLUSION: Performance of POCUS may reduce EDLOS in children with NMI.

Incidence and Clinical Features of Esophageal Perforation Caused by Ingested Foreign Body / 대한소화기학회지

BACKGROUND/AIMS: Esophageal perforation is a rare but often a life-threatening condition. However, the incidence and clinical features of esophageal perforation caused by ingested foreign body are unknown. This study investigated the incidence of esophageal perforation caused by ingested foreign body and evaluated the clinical features and outcome of patients with esophageal perforation. METHODS: Among a total of 196 adult patients with confirmed esophageal foreign body and complained of at least one of the related symptoms at the emergency department between January 2000 and July 2008, 18 patients with esophageal perforation due to esophageal foreign body ingestion were included in the study. Data were collected by retrospectively reviewing the electric medical records. RESULTS: The incidence of esophageal foreign body and esophageal perforation in adults was 19.4% (196/1,009) and 1.8% (18/1,009), respectively. Chest pain was the most common symptom and fishbone was the most common foreign body causing esophageal perforation. Mediastinitis or mediastinal abscess occurred in 13 patients (13/18, 72.2%). About half (8/18) of the patients were admitted to the intensive care unit but there was no in-hospital mortality. CONCLUSIONS: The incidence of esophageal perforation in patients with foreign body ingestion was low but it increased up to 9.2% in patients with esophageal foreign body. However, prognosis was favorable with timely proper treatment. Chest pain can be an ominous sign indicating the presence of esophageal perforation in patients with esophageal foreign body.

Value of Cardiac Biomarkers for Predicting Hypotension in Non-high-risk Patients with Acute Pulmonary Embolism

PURPOSE: Recent and numerous studies have indicated that cardiac biomarker elevation during acute pulmonary embolism (PE) predicts in-hospital death. However, the role of cardiac biomarkers for predicting the occurrence of hypotension is unknown. The aim of the present study was to evaluate whether increased levels of cardiac biomarkers can predict the occurrence of hypotension (sytolic blood pressure (SBP) 0.05 ng/mL) upon admission were an independent predictor for developing hypotension within 24 hours in patients with stable acute PE at the time of ED admission (odds ratio 11.0, 95% confidence interval (CI) 2.8-43.8, p=0.00). CONCLUSION: In stable patients with acute PE, an elevated TnI can predict the in-hospital development of hypotension within 24 hours. This finding is valuable for selecting patients who might benefit from intensive clinical surveillance and escalated treatment.

Is Colonoscopy Necessary in Children Suspected of Having Colonic Polyps?

BACKGROUND/AIMS: The clinical spectrum, histology, and endoscopic features of colonic polyps in the pediatric age group were studied to evaluate the role of colonoscopy in children suspected of having colonic polyps. METHODS: Seventy-six patients with colorectal polyps were studied. Investigations included barium enema (n=6), sigmoidoscopy (n=17), and colonoscopy (n=53) at the initial visit. Colonoscopy was also performed in 23 patients who received barium enema or sigmoidoscopy. Data related to age, gender, family history, signs, symptoms, size, location, polyp types, and associated diseases were collected and analyzed. RESULTS: Among the 76 patients, juvenile polyps were detected in 58 (76.3%), potentially premalignant polyposis in 17 (22.4%), familial adenomatous polyposis in 11 (14.5%), Peutz-Jegher syndrome in 4 (5.3%), and juvenile polyposis syndrome in 2 (2.6%). Twenty-two patients (28.9%) had polyps in the upper colon. All patients with potentially malignant polyps had polyps in both the upper colon and rectosigmoid colon. CONCLUSIONS: Although most of the children with colorectal polyps had juvenile polyps, a significant number of cases showed multiple premalignant and proximally located polyps. This finding emphasizes the need for a colonoscopy in such patients. Thus, the risk of malignant change, particularly in children with multiple polyps, makes surveillance colonoscopy necessary.

Helicobacter pylori Urease Activity is Influenced by Ferric Uptake Regulator

PURPOSE: The role of the Ferric Uptake Regulator (FUR) in the acid resistance of Helicobacter pylori (H. pylori) has been thought to be independent of urease. However, we demonstrated in this study that Fur influences urease activity. MATERIALS AND METHODS: A fur knockout mutant of H. pylori was constructed by replacing the Fur gene with a kanamycin resistant marker gene. The wild-type H. pylori and fur mutant were compared for survival. The integrity of the inner membrane of the bacteria was evaluated by confocal microscopy using membrane-permeant and -impermeant fluorescent DNA probes. Urease activity of intact H. pylori was measured between pH 3 and 8. Real time PCR of both strains was performed for urease genes including ureI, ureE, ureF, ureG, and ureH. RESULTS: The fur deletion affected the survival of H. pylori at pH 4. The urease activity curve of the intact fur mutant showed the same shape as the wild-type but was 3-fold lower than the wild-type at a pH of less than 5. Real time PCR revealed that the expression of all genes was consistently down-regulated in the fur mutant. CONCLUSION: The results of this study showed that fur appears to be involved in acid resistant H. pylori urease activity.

Electrically-evoked Neural Activities of rd1 Mice Retinal Ganglion Cells by Repetitive Pulse Stimulation

For successful visual perception by visual prosthesis using electrical stimulation, it is essential to develop an effective stimulation strategy based on understanding of retinal ganglion cell (RGC) responses to electrical stimulation. We studied RGC responses to repetitive electrical stimulation pulses to develop a stimulation strategy using stimulation pulse frequency modulation. Retinal patches of photoreceptor-degenerated retinas from rd1 mice were attached to a planar multi-electrode array (MEA) and RGC spike trains responding to electrical stimulation pulse trains with various pulse frequencies were observed. RGC responses were strongly dependent on inter-pulse interval when it was varied from 500 to 10 ms. Although the evoked spikes were suppressed with increasing pulse rate, the number of evoked spikes were >60% of the maximal responses when the inter-pulse intervals exceeded 100 ms. Based on this, we investigated the modulation of evoked RGC firing rates while increasing the pulse frequency from 1 to 10 pulses per second (or Hz) to deduce the optimal pulse frequency range for modulation of RGC response strength. RGC response strength monotonically and linearly increased within the stimulation frequency of 1~9 Hz. The results suggest that the evoked neural activities of RGCs in degenerated retina can be reliably controlled by pulse frequency modulation, and may be used as a stimulation strategy for visual neural prosthesis.

The Effects of Wearing Protective Devices among Residents and Volunteers Participating in the Cleanup of the Hebei Spirit Oil Spill / 예방의학회지

OBJECTIVES: To assess the protective effects of wearing protective devices among the residents and volunteers who participated in the cleanup of the Hebei Spirit oil spill. METHODS: A total of 288 residents and 724 volunteers were surveyed about symptoms, whether they were wearing protective devices and potential confounding variables. The questionnaires were administered from the second to the sixth week following the accident. Spot urine samples were collected and analyzed for metabolites of 4 volatile organic compounds (VOCs), 2 polycyclic aromatic hydrocarbons (PAHs), and 6 heavy metals. The association between the wearing of protective devices and various symptoms was assessed using a multiple logistic regression adjusted for confounding variables. A multiple generalized linear regression model adjusted for the covariates was used to test for a difference in least-square mean concentration of urinary biomarkers between residents who wore protective devices and those who did not. RESULTS: Thirty nine to 98% of the residents and 62-98% of volunteers wore protective devices. Levels of fatigue and fever were higher among residents not wearing masks than among those who did wear masks (odds ratio 4.5; 95% confidence interval 1.23-19.86). Urinary mercury levels were found to be significantly higher among residents not wearing work clothes or boots (p<0.05). CONCLUSIONS: Because the survey was not performed during the initial high-exposure period, no significant difference was found in metabolite levels between people who wore protective devices and those who did not, except for mercury, whose biological half-life is more than 6 weeks.

Primitive Neuroectodermal Tumor of the Liver in a 13-year-old Boy: A Case Report / 대한소아소화기영양학회지

Primary primitive neuroectodermal tumor (PNET) of the liver is a rare disease with aggressive behavior and poor prognosis. We report a case of a PNET of the liver in a 13-year-old boy. The patient was admitted to the hospital with fever and abdominal pain. Abdominal CT and MRI revealed a 5.5 cm sized, septated, non-enhancing mass in the hepatic hilum. The patient was initially diagnosed with an inflammatory pseudotumor. Despite 9 days of antibiotic therapy, the patient's clinical symptoms did not improve. A liver biopsy was performed in the interest of formulating a differential diagnosis. This procedure revealed tumor cells positive for CD99 on immunohistochemistry. The patient was diagnosed with a PNET.

Primitive Neuroectodermal Tumor of the Liver in a 13-year-old Boy: A Case Report / 대한소아소화기영양학회지

Primary primitive neuroectodermal tumor (PNET) of the liver is a rare disease with aggressive behavior and poor prognosis. We report a case of a PNET of the liver in a 13-year-old boy. The patient was admitted to the hospital with fever and abdominal pain. Abdominal CT and MRI revealed a 5.5 cm sized, septated, non-enhancing mass in the hepatic hilum. The patient was initially diagnosed with an inflammatory pseudotumor. Despite 9 days of antibiotic therapy, the patient's clinical symptoms did not improve. A liver biopsy was performed in the interest of formulating a differential diagnosis. This procedure revealed tumor cells positive for CD99 on immunohistochemistry. The patient was diagnosed with a PNET.

The Endocrine Manifestations and Growth of the Patients with 22q11.2 Microdeletion Syndrome / 대한소아내분비학회지

PURPOSE:Varying clinical phenotypes are associated with the chromosome 22q11.2 microdeletion syndrome. The endocrine manifestation are latent or overt hypoparathyroidism, thyroid dysfunction and short stature. This study was undertaken to investigate frequencies of endocrine abnormalities and short stature in patients with the chromosome 22q11.2 microdeletion syndrome. METHODS:Forty three unrelated patients were diagnosed having chromosome 22q11.2 microdeletion syndrome. Chromosomal microdeletion was confirmed by fluorescent in situ hybridation (FISH) with DNA probe (22q11.2 LSI TUPLE1 from Vysis). Serum total calcium and intact parathyroid hormone (PTH) were measured in all patients. Thyroid function tests including free thyroxine(T4), thyroid stimulating hormone (TSH) and thyroid autoantibodies were performed in all patients. Insulin-like growth factor-1 (IGF-1) was measured in 10 patients. Height, weight and body mass index were compared with chronological age in all patients. RESULTS:Seven patients (16%) had an overt hypoparathyroidism, presenting with hypocalcemic tetany. Thirteen patients (31%) showing hypocalcemia with normal PTH were regarded as having latent hypoparathyroidism since their PTH secretion response was blunted. Out of 2 patients with thyroid diseases, one patient had Graves disease and the other had Hashimoto thyroiditis. Five patients (12%) were below the 3rd percentile in height at evaluation. The BMI was below the 5th percentile in 23% of patients. CONCLUSION: Twenty patients (47%) presented with overt and latent hypoparathyroidism. Interestingly, autoimmune thyroid diseases such as Graves disease and Hashimoto thyroiditis were associated in patients with chromosome 22q11.2 microdeletion, indicating predisposition to autoimmune disorders. Therefore, a careful endocrine and growth evaluation is needed in these patients.

Influence of Hypoxia on Vascular Endothelial Growth Factor and Basic Fibroblast Growth Factor in Cultured Human Trophoblast / 대한산부인과학회잡지

OBJECTIVE: To investigate whether the hypoxic condition influences on the expression of vascular endothelial growth factor (VEGF) and basic fibroblast growth factor (bFGF) mRNA in the cultured human trophoblast. METHODS: Trophoblasts were isolated from the normal placenta in early pregnancy (6-10 weeks in gestation). Isolated trophoblasts were cultured under normoxic (5% CO2, 95% humid air in incubator) and hypoxic (MERCK, 1% O2, 99% CO2) conditions for 24, 48 and 72 hours, respectively. Total RNA was extracted from the cultured trophoblasts in each culture condition. The expressions of VEGF and bFGF mRNA were determined by reverse transcription-polymerase chain reaction (RT-PCR) and Northern blot analysis. RESULTS: The expression of VEGF189 mRNA was significantly increased in the hypoxic condition compared to the normoxic condition and control after 24 hours (p<0.05, p<0.05, respectively). The expression of VEGF206 mRNA was also significantly increased in the hypoxic condition compared to the normoxic condition and control after 48 hours (p<0.05, p<0.05, respectively). However, there was no significant difference between the normoxic and hypoxic conditions in the expression of VEGF121 and VEGF165 mRNA. The expression of bFGF mRNA was significantly increased in the hypoxic condition compared to the normoxic condition and control at 24 hours and 48 hours (p<0.05, p<0.05, respectively). bFGF mRNA was more expressed than VEGF mRNA in the hypoxic condition. CONCLUSION: These findings suggest that the hypoxic condition may stimulates the expression of bFGF and VEGF mRNA, and besides bFGF may be a more potent inducer of angiogenesis rather than VEGF in early human gestation.

A Case of Coil Embolization in a 15-year-old Child with Pulmonary Sequestration

Pulmonary sequestration is a rare congenital mass of nonfunctional pulmonary tissue that lacks a normal-connection with the bronchial tree or the pulmonary arteries. It is clinically asymptomatic but when it is complicated with recurrent infection, it needs to be treated. Conventionally, surgical removal was recommended, but these days we are trying new and less invasive techniques, such as arterial embolization. There were several reports about successful cases of pulmonary sequestration treated by embolization, but mostly all of them were done to newborns or infants. We report a case of a 15-year-old boy with an asymptomatic pulmonary sequestration on whom was performed coil embolization, and in the follow-up computed tomography(CT), the size of the lesion was decreased. He did not suffer severe respiratory symptoms.

Expression of alpha-smooth muscle actin and collagenIV in villous stroma of placental terminal villi and congestion fetal capillary in growth restricted pregnancies with severe preeclampsia / 대한산부인과학회잡지

OBJECTIVE: Preeclampsia is the major cause of prenatal mortality and morbidity. The functional disorder of uteroplacental insufficiecy is caused by the impaired uteroplacental blood flow and diffusion barrier in the villi. Functional disorders like placental circulating disorders results in morphological changes of terminal. villi as functional unit of placenta. We studied to investigate the differences in villous stoma of placental terminal villi and fetal capillary between growth restricted pregnancies with severe preeclampsia and normal preterm pregnancies. METHOD: Terminal villi was examined using light microscopy and by immunohistochemical localization of matrix molecule (alpha-smooth muscle actin and collagenIV) and the immunoreactivity of alpha-smooth muscle actin and collagenIV were evaluated in 17 cases of severe preeclampsia with intrauterine growth restriction as a study group and in 17 cases of gestational age matched normotensive preterm pregnancies as a control group. Fetal capillary congestion in terminal villi was also evaluated by Hematoxylin-Eosin staining. The patterns of immunohistochemical staining were all determinated in a visual qualitative manner (0-25%: -, 25-50%: +, 50-75%: ++, 75-100%: +++) by one pathologist. Congestion was considered to be present in a failed where the majority (>90%) of the capillaries demonstrated densely packed erythrocyte. RESULT: Expression of alpha-smooth muscle actin in the terminal villous stroma was significantly increased in study group compared with control group (P=0.0001). Expression of collagen IV in the terminal villous stroma was significantly increased in study group compared with control group (P=0.0001). Fetal capillary congestion was also significantly increased in study group compared with control group (P=0.049). CONCLUSION: The result suggests that there be the structural or biochemical difference in the villous stroma between normotensive preterm pregnancies and severe preeclampsia with intrauterine growth restriction and that the extravascular contractile system might be in the villous stroma in the severe preeclampsia intrauterine growth restriction.