Endovascular treatment of an intramural aortic haematoma following cardiopulmonary resuscitation for myocardial ischemia with ventricular fibrillation.

Cardiopulmonary resuscitation by manual cardiac compression can restore cardiocirculatory function but can also injure patients. Commonly reported are skeletal fractures of the rips and sternum, while injuries to the large thoracic vessels will frequently be lethal. We report the case of a 57-year-old male patient with sudden cardiac arrest because of myocardial ischemia with ventricular fibrillation, successful cardiopulmonary resuscitation, associated with an intramural haematoma (IMH) of the descending thoracic aorta treated by endovascular aortic repair. Secondary coronary angiography revealed a severe three vessel coronary disease with an occlusion of the proximal anterior descending branch and a subtotal stenosis of the first segmental branch of the left coronary artery (LCA) and a high-grade stenosis of the posterolateral segmental branch of the circumflex left coronary artery. Stenotic segments of coronary arteries were treated successfully by implantation of three drug-eluting stents followed by dual antiplatelet therapy. The patients recovered almost completely and was discharged for further rehabilitation after 3 weeks.

Hygroma colli cysticum: prenatal diagnosis and prognosis.

The objective of this study is to analyze the prenatal management and prognostic factors of hygroma colli cysticum by using cytogenetic tests and sonographic morphological features. All cases with hygroma colli cysticum diagnosed and managed at our Prenatal Diagnostics Unit between January 96 and September 2000 were analyzed. Sonographic morphological features were divided in two groups; nonseptated (n = 18) and septated (n = 12) hygroma colli cysticum lesions were compared with fetal karyotype results and pregnancy outcome data. Statistical analysis was performed by Chi-square test and statistical significance was defined as p <0.05. In 5 years, 30 cases with hygroma colli cysticum were identified. Cytogenetic results were obtained from 23 (76.7%) cases (four chorionic villus sampling and 19 amniocentesis). Chromosomal abnormalities were present in 13 cases (56.5%). The most common chromosomal abnormality was Turner Syndrome (four cases, 17.4%) and Trisomy 18 (four cases, 17.4%). Pregnancy outcome data were available for 29 patients. Those fetuses with septated hygroma colli cysticum tended to have a worse fetal outcome, without statistical significance (p >0.05), compared with the nonseptated hygroma colli cysticum cases (75 vs. 61.1%, respectively). Fetal hygroma colli cysticum, either septated or not, carries high risks of aneuploidies and adverse fetal outcome. Recommended management includes karyotyping and if parents decide to continue the pregnancy ultrasound scan at 20 to 22 weeks' gestation is necessary, for excluding associated anomalies. At birth, if the cystic hygroma persists, it should be noted that a respiratory difficulty can happen and a pediatrician should standby as a precaution.

Evaluation of the secretion of the atrial natriuretic factor (ANF) after laparotomy.

BACKGROUND: ANF is a potent diuretic, natriuretic and vasorelaxant hormone. The objective of the present study was to examine the effect of opioid receptor stimulation by morphine after surgery on endogenous ANF production and diuresis. METHODS: Prospectively, 11 women undergoing surgery for either uterine leiomyomas, chronic pelvic discomfort or desire for definitive contraception by laparotomy were evaluated. Venous samples were collected at fixed times. Concentrations of ANF were measured by commercially available radioimmunoassay test kits. Statistical analysis was performed by the Friedman Two way ANOVA. Kruskal-Wallis 1-way ANOVA and Mann-Whitney U-Wilcoxon Rank Sum W Test. The level of significance was set at probability below 0.05. RESULTS: There were statistically significant changes in the serum levels of ANF (p=0.0028), in pain score (p<0.0001) and urinary flow rate (p<0.0001) after operation, while the diastolic (p=0.0671) and systolic (p=0.0543) blood pressure showed slightly significant changes. CONCLUSION: Our results show that i.v. administered morphine induces a potent diuretic effect via activation of opioid receptors and suggest that this effect is due to the enhanced release of ANF. However the mechanism by which morphine induces the ANF release remains to be evaluated.

Heterologous mullerian mixed tumor after whole body irradiation because of Hodgkin's disease in stage IV.

PURPOSE: With an incidence of 1.5% of all malignant diseases of the uterus as specified in the literature, the mullerian mixed tumor is a rarity amongst the malignancies of the female genital tract. METHODS: A retrospective analysis of an individual case report with the occurrence of heterologous mullerian mixed tumor years after irradiation because of Hodgkin's disease. RESULTS: This case reports describes the occurrence of a mullerian mixed tumor 12 years after the treatment of Hodgkin's disease by whole body irradiation. To our knowledge, the incidence of a mullerian mixed tumor after the treatment of Hodgkin's disease has rarely been described up to now in the literature. CONCLUSION: This case report appears to indicate the possible carcinogenic potency of radiotherapy when administered many years before. A causal connection between the administration of whole body irradiation and the development of a mullerian mixed tumor cannot be established.

[Effect of hypertensive pregnancy complications on neonatal outcome of growth retarded fetuses]. / Einfluss hypertensiver Schwangerschaftskomplikationen auf das neonatale Outcome wachstumsretardierter Feten.

OBJECTIVE: To determine the effect of hypertensive disorders in pregnancy on the neonatal outcome of growth restricted fetuses. There is conflicting data on the effect of hypertension during pregnancy on the incidence of neonatal respiratory distress syndrome (RDS) and intraventricular hemorrhage. Some studies report a lower incidence of RDS and intraventricular hemorrhage in infants of hypertensive mothers, whereas other studies report a similar or higher incidence in infants born to hypertensive mothers. STUDY DESIGN: We performed a retrospective analysis of 220 growth restricted fetuses born between January 1, 1996 to July 1, 1997 at the Department of Obstetrics and Gynecology of the University-Hospital at Homburg/Saar. Data were obtained by review of the medical records. Growth restricted infants born to preeclamptic women or women with HELLP syndrome were compared to growth restricted fetuses born to mothers without hypertensive disorders. RESULTS: Growth restricted fetuses born to hypertensive mothers had a significant lower birth weight (p < 0.05). The incidence of RDS in children born to hypertensive mothers was significantly higher (p < 0.05, p < 0.01) and they stayed significantly longer in the neonatal intensive care unit (p < 0.01). In contrast to infants born to mothers with HELLP syndrome (n = 7) there was no difference in the incidence of intraventricular hemorrhage, infection, sepsis, necrotizing enterocolitis or cardiac complications (arrhythmia, insufficiency) in case of preeclampsia (n = 68). The perinatal mortality of infants born to hypertensive mothers was significantly higher (p < 0.05, p < 0.01). CONCLUSION: This study does not support the contention that hypertensive disorders in pregnancy have a beneficial effect on the postnatal course of IUGR infants.

Omphalocele and gastroschisis: prenatal diagnosis and peripartal management. A case analysis of the years 1989-1997 at the Department of Obstetrics and Gynecology, University of Homburg/Saar.

OBJECTIVE: The article presents a retrospective analysis (1989-1997) of the prenatal diagnosis, the course and completion of pregnancy of 26 fetuses with omphalocele and 18 fetuses with gastroschisis. SUBJECTS: 44 pregnancies with anterior fetal wall defect diagnosed by prenatal ultrasound, clinical or patho-anatomic examination between 1989 and 1997 at the Department of Obstetrics and Gynecology, University of Homburg/Saar. RESULTS: In 40 of 44 pregnancies (91%) the fetal ventral abdominal wall defect could be detected antenatally with ultrasound. Associated malformations in fetuses with omphalocele were seen in 18 cases (69%), whereas only five fetuses with gastroschisis (28%) had an associated malformation. Nineteen of 26 fetuses (73%) with omphalocele had a normal karyotype. Seven of 26 fetuses (27%) with omphalocele had an abnormal karyotype. Eleven fetuses with omphalocele were live born, three of them with minor anomalies. Ten babies with omphalocele survived. No chromosomal anomalies were detected in fetuses with gastroschisis. There were four gastrointestinal malformations and one lethal associated malformation in fetuses with gastroschisis. There were 15 live born babies with gastroschisis, all of whom have survived. In 20 of 44 cases (45%) with ventral abdominal wall defect oligohydramnios could be detected by ultrasound. In 28 of 44 cases (64%) we found fetal growth retardation <10th percentile for gestational age. CONCLUSION: In case of a fetal ventral abdominal wall defect, the detection and appropriate classification of associated fetal anomalies is of great importance for the further course of pregnancy. Fetal karyotyping should be offered in case of a fetal abdominal wall defect. Early and close prenatal consultation of the neonatologist and the pediatric surgeon will favorably influence the perinatal outcome.

Maternal and neonatal outcome of twin pregnancies complicated by single fetal death.

OBJECTIVE: To study the maternal and neonatal outcome of twin pregnancies complicated by the intrauterine death of one fetus after 20 weeks of gestation. DESIGN: Retrospective, observational study of 7 twin pregnancies out of 185 twin pregnancies with the diagnosis of a single intrauterine death over a 5-years period in a university hospital. RESULTS: The incidence of single fetal death in twin gestation after 20 weeks was 3.8% in the study population with a high incidence of intrauterine growth retardation (IUGR) of the remaining fetus and preeclampsia in the further course of pregnancy. The incidence of preterm delivery was 71% with a mean gestational age of 33.0 +/- 1.0 weeks. The median interval from diagnosis of single fetal death to delivery was 10.2 +/- 4.1 days (range 1-28 days). 5 of 7 (71%) cases were delivered by cesarean section for standard obstetrical reasons. Neither perinatal nor neonatal death of the remaining twin were observed. Two cases of neurologic injury were diagnosed after delivery by ultrasound and MRI. No maternal coagulopathy related to single fetal death occurred. CONCLUSION: Expectant management of single fetal death in twin pregnancies might be advisible under close surveillance of both, mother and the surviving fetus.

Immunohistochemical detection of apoptosis in the human term and post-term placenta.

PURPOSE: To study the incidence of apoptosis in human term and post-term placenta and to determine its presence in different areas of placentas of uncomplicated pregnancies. METHODS: A total of 15 placentas, 8 obtained from spontaneous deliveries and elective caesarean sections at term (37-41 weeks of pregnancy) and 7 from spontaneous deliveries and elective caesarean sections post-term (> 41 weeks of pregnancy) were included in this study. Apoptosis was identified by the terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick end-labeling method (TUNEL, Boehringer, Mannheim, Germany) in paraffin-embedded sections. RESULTS: Apoptosis was predominantly detected in trophoblast and stromal tissue. There were no significant differences in the incidence of apoptosis in different parts of placental tissue. A significant increase of apoptosis was seen in both trophoblast and stromal cells of post-term placentas (p < 0.05; p < 0.005). CONCLUSIONS: Apoptosis could be detected in the human term and post-term placenta, with increasing incidence in post-term placental tissue, suggesting a possible role of apoptosis in the mechanism of parturition and placental senescence.

Nucleated red blood cells in cord blood of singleton term and post-term neonates.

OBJECTIVE: This study aims to determine if nucleated red blood cells are elevated in pregnancies that continue beyond 289 days of gestation. STUDY DESIGN: Cord blood was prospectively collected from term and post-term singleton gestations from August 1 to December 31, 1998. Umbilical artery nucleated red blood cells were counted per 100 white blood cells. The comparison was made between pregnancies ending at 261-289 days (37.1-41.2 weeks) of gestation and those ending after 289 days (> or = 41.3 weeks) of gestation. RESULTS: Cord blood from 304 cases was obtained and evaluated for nucleated red blood cells per 100 white blood cells. The mean value of nucleated red blood cells per 100 white blood cells in the post-term neonate group was significantly higher than in the term neonate group (median 6.5, range 0-24 vs. median 3.7, range 0-14; p < 0.05). The values did not vary by fetal presentation, mode or duration of delivery. Neonatal outcome was comparable between both study groups. CONCLUSION: In post-term gestation after 289 days nucleated red blood cells in cord blood are significantly increased. These results point towards a different fetal oxygenation in post-term pregnancies beyond 289 days of gestation and support the current practice of very close testing of fetal well-being under those circumstances.

Maternal and neonatal outcome in a monochorionic twin pregnancy complicated by single intrauterine demise.

Single fetal death in monochorionic pregnancies is believed to be associated with increased risk of perinatal morbidity and mortality for the living twin and risk of coagulopathy affecting the mother. In this report we present a case of single intrauterine death in a monochorionic twin gestation diagnosed in the 28th week of pregnancy.

Immunohistochemical evaluation of apoptosis in placentae from normal and intrauterine growth-restricted pregnancies.

OBJECTIVE: To investigate the extent of apoptosis within the human placenta in tissues from normotensive term pregnancies and those complicated by intrauterine growth-restriction (IUGR). METHODS: A total of 18 placentas, 10 obtained from uncomplicated term gestations and 8 from intrauterine growth restricted fetuses were included in this study. Apoptosis was identified using a terminal deoxynucleotidyl transferase-mediated deoxyuridine triophosphate nick end-labeling technique (TUNEL, Boehringer, Mannheim, Germany) in paraffin-embedded sections. RESULTS: Apoptosis was predominantly detected in the villous trophoblast and stromal tissue. There were no differences in the incidence of apoptosis in different parts of the same placenta. The apoptotic index in placental tissue from uncomplicated pregnancies was 0.93 +/- 0.12. Significantly more apoptotic nuclei were detected in the placental tissue from IUGR gestation (4.2 +/- 2.96, p < 0.01). CONCLUSION: These results might point toward a possible role of apoptosis in the pathophysiology of intrauterine growth-restriction.

Effects of hemorrhage, hypoxia, and intravascular coagulation on bacterial clearance and translocation.

OBJECTIVE: This study was undertaken to discover if impaired blood clearance functions and killing capacity of the reticuloendothelial system contribute to the high occurrence rate of septic complications after shock, trauma, and thermal injury. DESIGN: Prospective, randomized, controlled trial. SETTING: Experimental laboratory in a university teaching hospital. SUBJECTS: Thirty-three standard-breed rabbits of either sex. INTERVENTIONS: Defined numbers of Escherichia coli (1.3 x 10(8)) colony-forming units were injected intravenously 60 min after induction of hypoxia, standardized by defined reduction of oxygen uptake (60% to 75% of baseline) induced by hypoventilation (n = 6) or hemorrhage (n = 6), after complete defibrination caused by the snake toxin, ancrod (n = 6), and after 60 mins without intervention (controls, n = 6). At 180 mins after bacterial injection, the animals were killed and tissue samples of liver, kidney, spleen, and lung were collected for microbiological examinations. MEASUREMENTS AND MAIN RESULTS: Bacterial elimination from the blood and distribution pattern of viable bacteria in liver, spleen, kidney, and lung were investigated in hemorrhagic, hypoxic, and defibrinated rabbits. Compared with controls, there was a distinct alteration of the elimination kinetics of bacteria from the circulating blood in the experimental groups. First, the initial counts of viable E. coli were up to 300% (p < .05) higher in the defibrination, hemorrhage, and hypoxia groups than in controls. Second, greater numbers of E. coli were found in the blood for a significantly (p < .001) longer period, coupled with up to four times higher counts in organ homogenates in the hemorrhagic and defibrinated groups (p < .01) and more than 100 times higher counts than control values in the hypoxic animals (p < .001). CONCLUSION: Hemorrhage, hypoxia, and intravascular coagulation induce impaired bacterial clearance from the blood that is associated with altered organ distribution patterns, thus reflecting dysfunction of the reticuloendothelial system.

Alterations of bacterial clearance induced by endotoxin and tumor necrosis factor.

The purpose of the study was to investigate the potential influence of endotoxin and tumor necrosis factor (TNF) on immune function in terms of systemic clearance and organ distribution of injected Escherichia coli in a rabbit model. To enable quantification of the clearance process, defined numbers of exogenous E. coli (1.3 x 10(8) CFU) were injected intravenously 60 min after bolus application of TNF (4 x 10(5) U, n = 6), after infusion of endotoxin (40 micrograms/kg of body weight) for 1 h (n = 6) or 4 h (n = 6), or after saline infusion (controls, n = 6). Parameters monitored were arterial pressure, oxygen uptake, and rates of bacterial elimination from the blood. At 180 min after E. coli injection, the animals were sacrificed, and tissue samples of liver, kidney, spleen, and lung were collected for bacterial counts. Endotoxin infusion produced a significant delay in blood clearance compared with saline and TNF pretreatment. The diminished systemic bacterial elimination was associated with significantly higher numbers of E. coli in the organs, thus reflecting reticuloendothelial system dysfunction. TNF had no major influence on the elimination kinetics of bacteria but affected the tissue distribution pattern with increased accumulation of E. coli in the lung (up to 100-fold of control values; P < 0.001).

Bilateral adrenal medullary hyperplasia: a clinicopathological entity.

A 36-year-old white patient is described. He received treatment for hypertension and showed slightly increased excretion of 17-OHCS- and 17-ketosteroids but no increase in values for 3-methoxy-4-hydroxymandelic acid in the urine. He was admitted to hospital for a myocardial infarction, which was found to be situated in the anterior wall. During his stay in hospital a sudden increase in blood pressure occurred, together with a typical attach of perspiration, loss of consciousness, and ventricular fibrillation. The assay by 3-methoxy-4-hydroxymandelic acid now showed markedly increased amounts. A phaeochromocytoma was thought to be the most probably diagnosis, but now withstanding therapy the patient died from cerebral lesions. At necropsy a recent anteroseptal myocardial infarction and some minor lesions were found but no tumour and notably no phaechromocytoma, neither in the adrenals nor elsewhere. Using Dobbie's morphometric technique, as described by Munro Neville (1969), changes in the adrenals were demonstrated, which were considered to represent primary adrenal medullary hyperplasia. Criteria for the diagnosis of this syndrome are discussed. Until now it had been presumed to be present in a number of cases but never convincingly demonstrated.