Acute appendicitis in pregnancy - do we treat correctly, or do we delay unnecessarily?

OBJECTIVES: Acute appendicitis is the most common non-gynaecological indication for surgical intervention during pregnancy. The aim of this study was to compare perioperative and postoperative results of surgical treatment of acute appendicitis in the early and late stage of pregnancy. MATERIAL AND METHODS: This is a retrospective study focused on the evaluation of perioperative and postoperative results of appendectomy in pregnancy. The study included all pregnant patients who underwent laparoscopic or open appendectomy at the University Hospital Ostrava during the observed 10-year period (January 2012-December 2021). The patients were divided into two subgroups according to the stage of pregnancy in relation to the expected viability of the foetus (the viability limit was defined as the 23rd week of pregnancy). RESULTS: In the monitored 10-year period, a total of 25 pregnant patients underwent appendectomy. Comparing the two subgroups of patients, there were no statistically significant differences in any of the admission parameters. Laparoscopy was performed in 100% of the patients in the lower stage of pregnancy (< 23 g.w.) and in 61% of the subgroup of patients with more advanced pregnancy (> 23 g.w.); this difference was statistically significant (p = 0.039). Differences in subgroups regarding duration of surgery, risk of revision and 30-day postoperative morbidity were not statistically significant. In the subgroup of patients < 23 g.w., uncomplicated forms of appendicitis predominated (66%), whereas in the subgroup > 23 g.w., complicated forms predominated (69%); this difference was statistically significant (p = 0.026). When comparing the two subgroups of patients, there was a statistically significant difference in the length of hospitalization (p = 0.006). The mortality rate of the group was zero. CONCLUSIONS: The results of the study confirm the fact that advanced pregnancy may be related to complicated forms of appendicitis. Therefore, early appendectomy is still the method of choice. In accordance with the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) recommendations, laparoscopic approach is preferred in pregnant patients, even in advanced pregnancy.

Microplastics and additives in patients with preterm birth: The first evidence of their presence in both human amniotic fluid and placenta.

Considering the well documented, almost ubiquitous nature of microplastics in different environments, the exposure of pregnant women to microplastics may pose risks to the unborn children. The study focused on investigating the presence of microplastics in amniotic fluid and placenta, and brings the first evidence of the simultaneous presence of microplastics and additives in both human amniotic fluid and placentas. In total, 20 samples of amniotic fluid and placenta from 10 patients were analyzed for the presence of microplastics and plastic additives by Fourier transform infrared spectroscopy - attenuated total reflectance (FTIR-ATR) after alkaline digestion with KOH. In 9 out of 10 patients, microplastics or additives were found in amniotic fluid, placenta, or both. Specifically, 44 particles of microplastics and polymer additives were identified in all samples. Chlorinated Polyethylene (CPE) and Calcium zinc PVC Stabilizer with particle sizes between 10 and 50 µm prevailed. Although all women involved in this study, who provided placenta and amniotic fluid samples, experienced physiological, singleton pregnancies complicated with preterm prelabour rupture of membranes (PPROM), it is too early to draw any conclusions and more research is needed.

L1CAM Is Not a Predictive Factor in Early-stage Squamous-cell Cervical Cancer.

AIM: Our study aimed to assess expression of L1 cell adhesion molecule (L1CAM) in early-stage cervical squamous-cell cancer as a prognostic factor. PATIENTS AND METHODS: This retrospective, single-institution study included 154 patients who underwent radical hysterectomy for early-stage squamous cell cervical cancer between 2007 and 2017. Tumor samples from 154 patients were available for L1CAM analysis by immunohistochemistry. Among all patients, radical abdominal hysterectomy was performed in 144 cases. RESULTS: L1CAM expression was positive in 24 tumors (15.6%) of the whole group. In relation to the grade of differentiation and the presence of lymphovascular invasion, L1CAM expression did not show an association (p=0.154 and p=0.306, respectively). The disease-free interval and overall survival also did not significantly differ between L1CAM-positive and L1CAM-negative cases (p=0.427 and p=0.240, respectively). For histopathological characteristics, L1CAM-positive cases had a significantly higher median tumor size (p=0.015). Even in the selected group of 115 cases without nodal infiltration, L1CAM status had no effect on the relapse rate during follow-up. CONCLUSION: Our study did not confirm the results of previous studies showing L1CAM expression to be a negative prognostic factor in cervical cancer. In our study, increased L1CAM expression in early-stage squamous-cell cervical cancer was not associated with adverse prognosis regarding disease recurrence, disease-free survival, nor overall survival. L1CAM expression was correlated only with the size of the tumor.

Is there a difference between acute appendicitis in pregnant and non-pregnant women?

OBJECTIVE: Acute appendicitis is the most common indication for surgical intervention during pregnancy for non-gynaecological or non-obstetric causes. The aim of this study was to compare perioperative and postoperative outcomes of acute appendectomies in pregnant and non-pregnant patients of childbearing age. METHODS: A retrospective clinical study focused on the comparison of perioperative and postoperative outcomes of acute appendectomy in pregnant and non-pregnant patients of reproductive age between January 2012 and December 2021 at the University Hospital in Ostrava. RESULTS: A number of 308 patients underwent acute appendectomy, 25 pregnant and 283 non-pregnant. There were no statistically significant differences in age, ASA (American Society of Anesthesiologists) classification, duration of complaints, baseline C-reactive protein values, sensitivity or specificity of sonography. A statistically significant difference was found in the leukocyte count between subgroups (P = 0.014) and in the number of laparoscopic procedures performed between the two subgroups (P < 0.001; 98.9% non-pregnant vs. 80.0% pregnant). There was also a statistically significant difference in the length of hospital stay, with the pregnant subgroup having a longer hospital stay (P = 0.014) and a statistically significant difference in the rate of postoperative complications between the defined subgroups (P = 0.039). Serious complications were described predominantly in the subgroup of pregnant patients, where they reached 12% compared to non-pregnant patients, where they were 2.8%. The mortality rate of the cohort was zero. CONCLUSION: The results of the study support the fact that pregnancy may be associated with complicated forms of acute appendicitis. Accurate and early diagnosis not only prevents the development of complicated forms of appendicitis but also reduces the number of negative appendectomies in pregnancy.

Religion Affects Future Female Doctors' Approach to HPV Vaccination in Czech and Slovak Republics.

The objective of this study is to summarize the factors, including religion, affecting an individual's decision to get vaccinated or reject vaccination. Anonymous questionnaire-based electronic study is conducted in all faculties of medicine in Czech and Slovak republics. One thousand four hundred and six (1406) questionnaires were analyzed. Responders not practicing any religion received vaccination more often and would recommend vaccination more often. Catholic religion was the most important demographic factor affecting the rate of vaccination. In the group of Catholic female students, 21.9% were vaccinated. In the group of non-Catholic female students, 55.5% were vaccinated. In conclusion, female medical students' approach to vaccination depends, among other factors, on their individual beliefs.

Cervical Gardnerella vaginalis in women with preterm prelabor rupture of membranes.

OBJECTIVE: To determine the association between microbial invasion of the amniotic cavity (MIAC) and/or intra-amniotic inflammation (IAI) and the cervical prevalence of Gardnerella vaginalis DNA in pregnancies with preterm prelabor rupture of membrane (PPROM). METHOD: In total, 405 women with singleton pregnancies complicated with PPROM were included. Cervical fluid and amniotic fluid samples were collected at the time of admission. Bacterial and G. vaginalis DNA were assessed in the cervical fluid samples using quantitative PCR technique. Concentrations of interleukin-6 and MIAC were evaluated in the amniotic fluid samples. Loads of G. vaginalis DNA ≥ 1% of the total cervical bacterial DNA were used to define the cervical prevalence of G. vaginalis as abundant. Based on the MIAC and IAI, women were categorized into four groups: with intra-amniotic infection (both MIAC and IAI), with sterile IAI (IAI without MIAC), with MIAC without IAI, and without either MIAC or IAI. RESULTS: The presence of the abundant cervical G. vaginalis was related to MIAC (with: 65% vs. without: 44%; p = 0.0004) but not IAI (with: 52% vs. without: 48%; p = 0.70). Women with MIAC without IAI had the highest load of the cervical G. vaginalis DNA (median 2.0 × 104 copies DNA/mL) and the highest presence of abundant cervical G. vaginalis (73%). CONCLUSIONS: In women with PPROM, the presence of cervical G. vaginalis was associated with MIAC, mainly without the concurrent presence of IAI.

Parents' request for termination of pregnancy due to a congenital heart defect of the fetus in a country with liberal interruption laws.

Objectives: This study aimed to evaluate the prenatal rate of congenital heart defects (CHDs) and the frequency of termination of pregnancy (TOP) due to a CHD, depending on the severity of the defect and concomitant diseases of the fetus.Methods: The data were assessed retrospectively between 2002 and 2017. Ultrasound examination was performed mostly in the second trimester. For analysis, the CHDs were divided into three groups of severity and three groups of fetus impairment.Results: A total of 40,885 fetuses underwent echocardiography. The CHDs were detected in 1.0% (398/40,885) and were an isolated anomaly in 69% (275/398). Forty-nine percent (197/398) of families decided to TOP. In all groups of severity, the rate of TOP rose linearly when comparing isolated defects and cases with associated morphological and genetic impairments. The TOP was significantly dependent on the associated anomalies in patients with the most correctable defects (p < .001) and the severity of CHDs in isolated cases without any other impairment (p < .001).Conclusion: The parents' decision to terminate increased with the severity of the defect and the associated anomalies of the fetus. The parents were mostly influenced by the associated anomalies when the CHD was correctable, and genetic factors played a more important role than morphological ones.

Lactobacilli-dominated cervical microbiota in women with preterm prelabor rupture of membranes.

BACKGROUND: To determine the association between microbial invasion of the amniotic cavity (MIAC) and the presence of Lactobacillus crispatus- or Lactobacillus iners-dominated cervical microbiota in pregnancies with preterm prelabor rupture of membrane. Next, to assess the relationship between the presence of L. crispatus- or L. iners-dominated cervical microbiota and short-term neonatal morbidity. METHOD: A total of 311 women were included. Cervical samples were obtained using a Dacron polyester swab and amniotic fluid samples were obtained by transabdominal amniocentesis. Bacterial DNA, L. crispatus, and L. iners in the cervical samples were assessed by PCR. Cervical microbiota was assigned as L. crispatus- or L. iners-dominated when the relative abundance of L. crispatus or L. iners was ≥50% of the whole cervical microbiota, respectively. RESULTS: Women with MIAC showed a lower rate of L. crispatus-dominated cervical microbiota (21% vs. 39%; p = 0.003) than those without MIAC. Lactobacillus crispatus-dominated cervical microbiota was associated with a lower rate of early-onset sepsis (0% vs. 5%; p = 0.02). CONCLUSIONS: The presence of L. crispatus-dominated cervical microbiota in women with preterm prelabor rupture of membrane was associated with a lower risk of intra-amniotic complications and subsequent development of early-onset sepsis of newborns.

Pentraxin 3 in Noninvasively Obtained Cervical Fluid Samples from Pregnancies Complicated by Preterm Prelabor Rupture of Membranes.

PROBLEM: To determine the changes of pentraxin 3 (PTX3) level in noninvasively obtained cervical fluid samples from women with preterm prelabor rupture of membranes (PPROM) based on the presence of microbial invasion of the amniotic cavity (MIAC) and/or intra-amniotic inflammation (IAI), and intra-amniotic infection (the presence of both MIAC and IAI). METHODS OF STUDY: A total of 160 women with PPROM were included. Cervical fluid samples were obtained using a Dacron polyester swab and amniotic fluid samples were obtained by transabdominal amniocentesis. Cervical fluid PTX3 levels were assessed using enzyme-linked immunosorbent assay. RESULTS: PTX3 was found in all the cervical fluid samples and its levels were higher in women with MIAC, IAI, and intra-amniotic infection than in women without these conditions. When the women were categorized into four subgroups based on the presence of MIAC and/or IAI, women with intra-amniotic infection had higher cervical fluid PTX3 levels than those with sterile IAI (IAI alone), colonization (MIAC alone), or no MIAC or IAI. A cervical fluid PTX3 level of 11 ng/mL was the best value for identifying the presence of intra-amniotic infection in women with PPROM. CONCLUSIONS: PTX3 is a constituent of cervical fluid of women with PPROM. Cervical fluid PTX3 level reflects the situation in the intra-amniotic compartments of women with PPROM. Cervical fluid PTX3 is a potential marker for the noninvasive identification of intra-amniotic infection in PPROM.

Congenital heart defects according to the types of the risk factors - a single center experience.

Objective: The main aim of this study was to compare the prevalence of congenital heart defects (CHDs) between pregnant women with and those without the risk factors. The secondary aim was to determine the influence of the specific risk factors, divided into subgroups, on the development of the CHD. Methods: The presented results were obtained over the course of a 15-year study between years 2002 and 2016. Fetal echocardiography was performed as a planned screening examination during the second trimester of gravidity. A total of 35,831 singleton pregnancies were examined at our center. Risk factors for the development of CHDs were analyzed and divide into the following groups: (i) maternal age ≥35 years; (ii) mother-related risk factors; (iii) pregnancy- and fetus-related risk factors; (iv) pregnancy after in vitro fertilization (IVF); (v) history of CHDs in the first-degree family member; (vi) history of CHDs in the second-degree family member; and (vii) positive genetic family history. Results: The risk factors were identified in 25% (8990/35,831) of pregnancies. In total, CHDs were detected in 1.1% (394/35,831) of fetuses. The prevalence rate of CHDs was higher in the pregnancies with than in those without the risk factors (2.5% [221/8990] versus 0.6% [173/26,841]; p < .0001). The presence of pregnancy- and fetus-related risk factors (odds ratio [OR], 6.5; 95% confidence interval [CI], 4.3-9.7) and pregnancy after IVF (OR, 2.8; 95% CI, 1.5-5.2) were found to be independent risk factors of CHDs. Conclusions: The presence of specific risk factors is related to the increasing prevalence of CHDs. Pregnancy- and fetus-related risk factors and in vitro fertilization were found to be the independent risk factors of CHD.

L1CAM as a Negative Prognostic Factor in Endometrioid Endometrial Adenocarcinoma FIGO Stage IA-IB.

AIMS: In this study, we aimed to investigate how positivity for L1 cell adhesion molecule (L1CAM) was associated with outcome and relapse pattern in patients with Fédération Internationale de Gynécologie et d'Obstétrique (FIGO) stage IA-IB endometrial cancer. MATERIALS AND METHODS: This retrospective study included 358 patients who underwent surgical treatment for endometrial carcinoma. Tumor samples from 312 patients (87.2%) were available for L1CAM analysis by immunohistochemistry. RESULTS: Of the 312 tumor samples analyzed, 93 (29.8%) were L1CAM-positive. L1CAM positivity was significantly more common in grade 3 compared to grade 1-2 carcinomas (p=0.02). Patients with L1CAM positivity more commonly experienced disease progression. Distant metastasis was significantly associated with L1CAM positivity (p=0.01). Progression-free interval and overall survival did not significantly differ between L1CAM-positive and L1CAM-negative cases. CONCLUSION: L1CAM is a promising independent prognostic marker associated with aggressive tumor behavior and recurrence risk, but not with overall survival.

Maternal white blood cell count cannot identify the presence of microbial invasion of the amniotic cavity or intra-amniotic inflammation in women with preterm prelabor rupture of membranes.

OBJECTIVE: The main aim of this study was to determine the relationship between the maternal white blood cell (WBC) count at the time of hospital admission in pregnancies complicated by preterm prelabor rupture of membranes (PPROM) and the presence of microbial invasion of the amniotic cavity (MIAC) and/or intra-amniotic inflammation (IAI). The second aim was to test WBC diagnostic indices with respect to the presence of MIAC and/or IAI. METHODS: Four hundred and seventy-nine women with singleton pregnancies complicated by PPROM, between February 2012 and June 2017, were included in this study. Maternal blood and amniotic fluid samples were collected at the time of admission. Maternal WBC count was assessed. Amniotic fluid interleukin-6 (IL-6) concentration was measured using a point-of-care test, and IAI was characterized by an IL-6 concentration of ≥ 745 pg/mL. MIAC was diagnosed based on a positive polymerase chain reaction result for the Ureaplasma species, Mycoplasma hominis, and/or Chlamydia trachomatis and/or for the 16S rRNA gene. RESULTS: Women with MIAC or IAI had higher WBC counts than those without (with MIAC: median, 12.8 × 109/L vs. without MIAC: median, 11.9 × 109/L; p = 0.0006; with IAI: median, 13.7 × 109/L vs. without IAI: median, 11.9 × 109/L; p < 0.0001). When the women were divided into four subgroups based on the presence of MIAC and/or IAI, the women with both MIAC and IAI had a higher WBC count than those with either IAI or MIAC alone, and those without MIAC and IAI [both MIAC and IAI: median, 14.0 × 109/L; IAI alone: 12.1 × 109/L (p = 0.03); MIAC alone: 12.1 × 109/L (p = 0.0001); and without MIAC and IAI: median, 11.8 × 109/L (p < 0.0001)]. No differences in the WBC counts were found among the women with IAI alone, MIAC alone, and without MIAC and IAI. CONCLUSION: The women with both MIAC and IAI had a higher maternal WBC count at the time of hospital admission than the remaining women with PPROM. The maternal WBC count at the time of admission showed poor diagnostic indices for the identification of the presence of both MIAC and IAI. Maternal WBC count at the time of admission cannot serve as a non-invasive screening tool for identifying these complications in women with PPROM.

Vacuum-assisted vaginal delivery and levator ani avulsion in primiparous women.

OBJECTIVE: We compared the incidence and type of levator ani avulsion diagnosed by translabial ultrasound evaluation in primiparous women six months after vacuum-assisted or spontaneous vaginal delivery. MATERIAL AND METHODS: This retrospective observational study was performed between January 2011 and December 2013. Primiparous women six months after vacuum-assisted vaginal delivery and after spontaneous vaginal delivery underwent translabial ultrasound evaluation. The distance between the urethra and fibers of the musculus levator ani puborectalis (levator-urethra gap) was measured. A levator-urethra gap >25 mm was considered a musculus levator ani avulsion. RESULTS: In total, 184 women participated in the study. Among them, 92 had vacuum extraction and 92 had uncomplicated spontaneous delivery. A longer levator-urethra gap on both sides of the pubic bone was found in women after vacuum-assisted vaginal delivery (p < 0.0001 for both sides). Musculus levator ani avulsion was identified in 20 women (unilateral in 16 cases and bilateral in four cases). No difference in an incidence of musculus levator ani avulsion was identified in women after vacuum-assisted vaginal delivery [11/92 (12%)] compared to spontaneous delivery [9/92 (10%); p = 0.81]. CONCLUSION: Vacuum-assisted vaginal delivery in primiparous women is associated with a longer levator-urethra gap but not with a higher frequency of avulsion of the musculus levator ani.

Toxic epidermal necrolysis complicating antibiotic treatment of puerperal endometritis: a case report.

The aim of the study is to describe a case report of Lyell syndrome (toxic epidermal necrolysis) involving 63% of body surface which has been associated with antibiotic therapy of mild peurperal endometritis in woman 3 weeks postpartum. Lyell syndrome is a severe life-threatening condition developing due to idiosyncrazy (alergic reaction type IV), most commonly after administration of drugs. Incidence quoted in literature is around 1:1-2000000. Illness severity can be assessed using a SCORTEN scoring system, which predicts patient mortality based on seven independent factors. Lyell syndrome is a very rare but potentially lethal complication of antibiotic treatment.

Agreement on intrapartum cardiotocogram recordings between expert obstetricians.

RATIONALE, AIMS AND OBJECTIVES: To evaluate obstetricians' inter- and intra-observer agreement on intrapartum cardiotocogram (CTG) recordings and to examine obstetricians' evaluations with respect to umbilical artery pH and base deficit. METHODS: Nine experienced obstetricians annotated 634 intrapartum CTG recordings. The evaluation of each recording was divided into four steps: evaluation of two 30-minute windows in the first stage of labour, evaluation of one window in the second stage of labour and labour outcome prediction. The complete set of evaluations used for this experiment is available online. The inter- and intra-observer agreement was evaluated using proportion of agreement and kappa coefficient. Clinicians' sensitivity and specificity was computed with respect to umbilical artery pH, base deficit and to Apgar score at the fifth minute. RESULTS: The overall proportion of agreement between clinicians reached 48% with 95% confidence intervals (CI) (CI: 47-50). Regarding the different classes, proportion of agreement ranged from 57% (CI: 54-60) for normal to 41% (CI: 36-46) for pathological class. The sensitivity of clinicians' majority vote to objective outcome was 39% (CI: 16-63) for the umbilical artery base deficit and 27% (CI: 16-42) for pH. The specificity was 89% (CI: 86-92) for both types of objective outcome. CONCLUSIONS: The reported inter-/intra-observer variability is large and this holds irrespective of clinicians' experience or work place. The results support the need of modernized guidelines for CTG evaluation and/or objectivization and repeatability by introduction of a computerized approach that could standardize the process of CTG evaluation within the delivery ward.

Vaginal fluid IL-6 and IL-8 levels in pregnancies complicated by preterm prelabor membrane ruptures.

OBJECTIVE: To determine the vaginal fluid interleukin (IL)-6 and IL-8 concentrations in pregnancies complicated by preterm prelabor rupture of membranes and their correlation to microbial invasion of the amniotic cavity (MIAC) as well as histological chorioamnionitis (HCA). METHODS: Sixty-eight women with singleton pregnancies were included in this study. Vaginal fluid was collected at the time of admission. IL-6 and IL-8 concentrations in the vaginal fluid were determined using ELISA. RESULT: Women with MIAC had higher vaginal fluid IL-6 levels compared to those without MIAC (with MIAC: median 374 pg/mL versus without MIAC: median 174 pg/mL; p = 0.03). IL-8 levels were higher in women with MIAC only in the crude analysis but not after adjustment for gestational age. There was no difference in the IL-6 and IL-8 concentrations between those with and without HCA. Women with both MIAC and HCA had higher IL-6 vaginal fluid levels than those without both MIAC and HCA (with MIAC and HCA: median 466 pg/mL versus without MIAC and HCA: median 178 pg/mL; p = 0.02). IL-8 levels were higher in women with MIAC and HCA only in the crude analysis but not after adjustment for gestational age. CONCLUSIONS: Vaginal fluid IL-6 but not IL-8 levels reflect the presence of MIAC and both MIAC and HCA.

Cervical fluid IL-6 and IL-8 levels in pregnancies complicated by preterm prelabor rupture of membranes.

UNLABELLED: Abstract Objective: To determine the cervical fluid interleukin (IL)-6 and IL-8 levels in pregnancies complicated by preterm prelabor rupture of membranes (PPROM) and the association of these interleukins with microbial invasion of the amniotic cavity (MIAC) and histological chorioamnionitis (HCA). METHODS: Sixty women with singleton pregnancies were included in this study. Cervical fluid was sampled at the time of admission using Dacron polyester swabs, which were placed into the endocervical canal for 20 s. IL-6 and IL-8 levels were determined by ELISA. The management of PPROM was active management (except for in pregnancies <28 weeks of gestation) and occurs not later than 72 h after the rupture of membranes. RESULT: The women with MIAC had higher IL-6 and IL-8 levels than did the women without MIAC (IL-6: p=0.01; IL-8: p=0.003). There was no difference in IL-6 levels between women with and without HCA (p=0.37). The women with HCA had higher IL-8 levels only in the crude analysis (p=0.01) but not after adjustment for gestational age (p=0.06). The women with both MIAC and HCA had higher levels of IL-6 and IL-8 than did the other women (IL-6: p=0.003; IL-8: p=0.001). IL-8 level of 2653 pg/mL was found to be the best cut-off point in the identification of PPROM pregnancies complicated by both MIAC and HCA with a likelihood ratio of 24. CONCLUSIONS: The presence of MIAC is the most important factor impacting the local cervical inflammatory response, which is determined by IL-6 and IL-8 levels in the cervical fluid. IL-8 levels seem to be a promising non-invasive marker for the prediction of pregnancies complicated by the presence of both MIAC and HCA.

Dosimetric comparison of MRI-based HDR brachytherapy and stereotactic radiotherapy in patients with advanced cervical cancer: A virtual brachytherapy study.

AIM: To evaluate the treatment plans of 3D image-guided brachytherapy (BT) and stereotactic robotic radiotherapy with online image guidance - CyberKnife (CK) in patients with locally advanced cervix cancer. METHODS AND MATERIALS: Ten pairs of plans for patients with locally advanced inoperable cervical cancer were created using MR based 3D brachytherapy and stereotaxis CK. The dose that covers 98% of the target volume (HR CTV D98) was taken as a reference and other parameters were compared. RESULTS: Of the ten studied cases, the dose from D100 GTV was comparable for both devices, on average, the BT GTV D90 was 10-20% higher than for CK. The HR CTV D90 was higher for CK with an average difference of 10-20%, but only fifteen percent of HR CTV (the peripheral part) received a higher dose from CK, while 85% of the target volume received higher doses from BT. We found a significant organ-sparing effect of CK compared to brachytherapy (20-30% lower doses in 0.1 cm(3), 1 cm(3), and 2 cm(3)). CONCLUSION: BT remains to be the best method for dose escalation. Due to the significant organ-sparing effect of CK, patients that are not candidates for BT could benefit from stereotaxis more than from classical external beam radiotherapy.

Changes in middle cerebral artery velocimetry of fetuses diagnosed postnatally with mild or moderate hemolytic disease.

OBJECTIVES: To determine the longitudinal trends of middle cerebral artery peak systolic velocity (MCA PSV) in fetuses with mild or moderate hemolytic disease according to the need for postnatal therapy. DESIGN: Prospective cohort study. SETTING: University referral center. SAMPLE: Twenty-three fetuses from singleton alloimmunized pregnancies. METHODS: Serial measurements of MCA PSV were performed. After delivery, newborns were grouped by the need for postnatal management into mild hemolytic disease, which required no or only phototherapy (n = 14, group 1), and moderate hemolytic disease, where postnatal top-up or exchange transfusions were required (n = 9, group 2). MAIN OUTCOME MEASURES: Serial Doppler MCA PSV data transformed to multiples of the median, analyzed with linear regression and exponential models. RESULTS: We performed 83 measurements in group 1: 3-8 per fetus; mean GA at inclusion, 23 weeks and 65 measurements in group 2: 4-15 per fetus; mean GA at inclusion, 22 weeks. The estimated mean slopes of the MCA PSVs increased with the degree of postnatal therapy required (group 1: MCA PSV = 0.003 GA + 1.298; group 2: MCA PSV = 0.035 GA + 0.436). The relative average increments (RAI) were 4.7% and 7.1%, respectively. The two groups exhibited significant differences in mean slope and RAI (p<0.05). CONCLUSIONS: Fetuses that required postnatal transfusions due to hemolytic disease showed an enhanced progressive increase in MCA PSVs compared to those without transfusion requirement. This information might enable their identification during pregnancy.