Placental pathology in a pregnant woman with severe COVID-19 and successful ECMO treatment: a case report.

BACKGROUND: Infection with SARS-CoV-2 during pregnancy can lead to a severe condition in the patient, which is challenging for obstetricians and anaesthesiologists. Upon severe COVID-19 and a lack of improvement after multidrug therapy and mechanical ventilation, extracorporeal membrane oxygenation (ECMO) is introduced as the last option. Such treatment is critical in women with very preterm pregnancy when each additional day of the intrauterine stay is vital for the survival of the newborn. CASE PRESENTATION: We report a case of a 38-year-old woman at 27 weeks of gestation treated with multidrug therapy and ECMO. The woman was admitted to the intensive care unit (ICU) with increasing fever, cough and dyspnoea. The course of the pregnancy was uncomplicated. She was otherwise healthy. At admission, she presented with severe dyspnoea, with oxygen saturation (SpO2) of 95% on passive oxygenation, heart rate of 145/min, and blood pressure of 145/90. After confirmation of SARS-CoV-2 infection, she received steroids, remdesivir and convalescent plasma therapy. The foetus was in good condition. No signs of an intrauterine infection were visible. Due to tachypnea of 40/min and SpO2 of 90%, the woman was intubated and mechanically ventilated. Due to circulatory failure, the prothrombotic activity of the coagulation system, further saturation worsening, and poor control of sedation, she was qualified for veno-venous ECMO. An elective caesarean section was performed at 29 weeks on ECMO treatment in the ICU. A preterm female newborn was delivered with an Apgar score of 7 and a birth weight of 1440 g. The newborn had no laboratory or clinical evidence of COVID-19. The placenta showed the following pathological changes: large subchorionic haematoma, maternal vascular malperfusion, marginal cord insertion, and chorangioma. CONCLUSIONS: This case presents the successful use of ECMO in a pregnant woman with acute respiratory distress syndrome in the course of severe COVID-19. Further research is required to explain the aetiology of placental disorders (e.g., maternal vascular malperfusion lesions or thrombotic influence of COVID-19). ECMO treatment in pregnant women remains challenging; thus, it should be used with caution. Long-term assessment may help to evaluate the safety of the ECMO procedure in pregnant women.

The analgesic efficiency of transversus abdominis plane (TAP) block after caesarean delivery.

OBJECTIVES: The ultrasound-guided transversus abdominis plane (TAP) block is a supporting method of pain relief after different types of surgical and gynecological procedures. The aim of the present study was to evaluate the analgesic effects of the TAP-block in patients undergoing caesarean section. MATERIAL AND METHODS: 88 women undergoing elective caesarean section under spinal anaesthesia were prospectively randomized into two groups. In the first group, an ultrasound-guided bilateral TAP block was performed using 40 mL 0.25% bupivacaine, while the second group was treated without a regional nerve block. Both groups received a standard analgesia protocol with intravenous paracetamol administered every 6 hours and intravenous tramadol on-demand, delivered using the Patient Controlled Analgesia (PCA) method. Pain intensity was assessed according to the visual analogue scale (VAS) directly after the TAP block and at 3, 6 and 12 hours postoperatively. Any patient complaints and side-effects during the postoperative period were recorded. RESULTS: The TAP block resulted in a significant reduction of pain intensity using the visual analogue scale after 3, 6 and 12 hours (p < 0.05) and a significant decrease in tramadol administration (p < 0.05) during the first 12 hours postoperatively. No significant differences in the heart rate and blood pressure were noted between groups (p > 0.05). There were no complications related to the TAP block. CONCLUSIONS: The TAP block is a safe and effective adjunctive method of pain relief after caesarean delivery.

Shoulder proprioception - lessons we learned from idiopathic frozen shoulder.

BACKGROUND: Of all the most frequent soft tissue disorders of the shoulder, idiopathic frozen shoulder (IFS) offers the greatest potential for studying proprioception. Studies concerning the presence of proprioception dysfunctions have failed to determine the potential for spontaneous healing of passive shoulder stabilizers (anterior and posterior capsule, middle and inferior gleno-humeral ligaments), its relationship with passive (PJPS) and active (AJPS) shoulder proprioception for internal and external rotation (IR, ER), as well as the isokinetic muscle performance of the internal and external rotators. This study investigates these dependencies in the case of arthroscopic release of IFS. METHODS: The study group comprised 23 patients (average aged 54.2) who underwent arthroscopic release due to IFS and 20 healthy volunteers. The average follow-up time was 29.2 months. The Biodex system was used for proprioception measurement in a modified neutral arm position and isokinetic evaluation. The results were analysed using the T-test, Wilcoxon and interclass correlation coefficient. P-values lower than 0.05 were considered significant. RESULTS: Statistically significant differences were found between involved (I) and uninvolved (U) shoulders only in the cases of PJPS and AJPS, peak torque, time to peak torque and acceleration time for ER (p < 0.05). No statistically significant difference was noted between PJPS IR and PJPS ER or between AJPS IR and AJPS ER (p > 0.05) for the U shoulders. CONCLUSIONS: The anatomical structure of anterior (capsule, middle and anterior band of inferior gleno-humeral ligament) and posterior (capsule and posterior band of inferior gleno-humeral ligament) passive shoulder restraints has no impact on the difference in PJPS values between ER and IR in a modified neutral shoulder position. The potential for spontaneous healing of the anterior and posterior passive shoulder restraints influences PJPS recovery after arthroscopic release of IFS. ER peak torque deficits negatively affect AJPS values. PJPS and AJPS of ER and IR can be measured with a high level of reproducibility using an isokinetic dynamometer with the arm in a modified neutral shoulder position. Differences greater than 15 % for PJPS and >24 % for AJPS for ER and IR can be helpful for future studies as baseline data for identification of particular passive and active shoulder stabilizers at risk.

Atrophy of type I and II muscle fibers is reversible in the case of grade >2 fatty degeneration of the supraspinatus muscle: an experimental study in rabbits.

BACKGROUND: Although clinical investigations indicate that the limit of reversibility of rotator cuff muscles fibers type I and II atrophy is grade 2 of fatty degeneration (FD) according to the Goutallier computed tomography classification, little is known about the morphometric verification of these findings. METHODS: The supraspinatus tendon was detached from the greater tubercle and the infraspinatus and subscapularis in 12 rabbits, and a 12-week observation period followed. This proved to be sufficient for development of grade >2 FD of the supraspinatus tendon. The tendon was then reinserted. The animals were euthanized 24 weeks after tendon reconstruction. The sections of middle part of supraspinatus were stained for adenosine triphosphatase reaction, and morphometric measurements were taken of type I and II muscle fiber diameters. The contralateral shoulders served as controls. RESULTS: The macroscopic inspection of the supraspinatus tendons revealed complete healing in all cases. No statistically significant differences were found between controls and operated-on shoulders for type I (P = .13) and type II (P = .55) muscle fibers. CONCLUSIONS: Atrophy of type I and II muscle fibers in rabbit supraspinatus muscle, characterized by grade >2 fatty degeneration according to the Goutallier computed tomography classification, is reversible after 24 weeks from reattachment of its tendon. A requirement for type I and II muscle fibers hypertrophy is a change in the biomechanical and functional conditions of the muscle after its tendon is reconstructed.

The evaluation of the influence of selected patellofemoral joint geometry indicators observed in magnetic resonance imaging on the incidence of anterior knee pain in patients after anterior cruciate ligament reconstruction using hamstrings.

BACKGROUND: Anterior knee pain (AKP) is a frequent serious clinical problem after anterior cruciate ligament (ACL) reconstruction, regardless of the graft material used. The author conducted prospective studies of the correlation between AKP and disturbed geometry of patello-femoral joint observed in magnetic resonance imaging (MRI), in patients with injured ACL reconstructed with the use of hamstrings. MATERIAL AND METHODS: The study included 60 patients (34 males and 26 females), at the mean age of 31, who underwent ACL reconstruction with flexors. Only patients without clinical AKP symptoms or AKP factors after reconstruction were included in the study. Before surgery, in all patients MRI was performed in order to evaluate the patellar height, excessive patellar pressure (EPP) and patellar lateralization (PL). In the postoperative course, AKP and its correlation with the ratios mentioned above were observed. RESULTS: In the group of patients included in the study, pathological patellar height was not observed, EPP was diagnosed in 15%, PL in 13.3% and EPP and PL jointly in 11.9% of the patients. AKP was observed in 8 out of 9 patients with abnormal lateral pressure, 7 patients with EPP and 7 patients with concomitant excessive lateral pressure and PL. The first symptoms of AKP appeared between the seventh and twelfth week after surgery and increased after 12 weeks. CONCLUSIONS: The occurrence of excessive lateral pressure syndrom (EPP) and PL confirmed in MRI was very strongly correlated (89% and 100%, respectively) with the occurrence of AKP after ACL reconstruction. The evaluation of the patellofemoral joint geometry, taking into account the EPP and PL ratios in pre-operative magnetic resonance image (MRI) in patients with injured anterior cruciate ligament, may allow us to establish the AKP risk group and administer suitable preventive treatment (prophylaxis).