Doppler and gray-scale sonographic classification of adnexal torsion.

OBJECTIVE: To propose, in cases with coiling of the ovarian vessels, a classification of severity of torsion based on Doppler and gray-scale ultrasound findings and to suggest a treatment strategy for each situation. METHODS: Seventeen patients were examined in a gynecological emergency room between December 1995 and February 2003 due to suspected adnexal torsion. Doppler and gray-scale ultrasound were used to visualize coiling of the ovarian blood vessels. Intraovarian flow was assessed by spectral Doppler and on this basis, along with the patient's clinical condition, the decision was made as to whether surgery was necessary. Findings on surgery were recorded. RESULTS: All 17 patients showed coiling of the ovarian vessels. Nine had arterial and venous blood flow within the ovary and ultrasound and surgical findings usually demonstrated normal sized or mildly enlarged ovaries. Five had only arterial blood flow within the ovary and surgery usually revealed enlarged ovaries with normal color or mild discoloration. Three had neither arterial nor venous blood flow within the ovary, with vessel coiling evident only on gray-scale and not on Doppler examination, and surgical findings included signs of ovarian ischemia or necrosis. CONCLUSION: In cases of coiling of the ovarian vessels, Doppler flow analysis of the ovary can help differentiate between ischemic adnexal torsion and coiling of the ovarian blood vessels without strangulation, aiding in the choice of treatment. According to type of blood flow seen on Doppler examination, we suggest the following classification of severity of adnexal torsion and treatment strategy: Class 1, coiling with arterial and venous ovarian blood flow; a conservative approach may be considered if the clinical condition permits; Class 2, coiling with arterial ovarian flow but no venous flow; surgical intervention is required; and Class 3, true strangulation, with no ovarian blood flow; urgent surgical intervention is required.

Johanson-Blizzard syndrome: a prenatal ultrasonographic diagnosis.

Johanson-Blizzard syndrome is a rare autosomal recessive disorder characterized by aplasia of alae nasi, pancreatic insufficiency, aplasia cutis, anorectal anomalies and postnatal growth restriction. In this case report, we describe the prenatal sonographic findings of Johanson-Blizzard syndrome in a 21-week pregnancy of a consanguineous couple. Sonographic findings of aplastic alae nasi (beak-like nose) and dilated sigmoid colon led to the prenatal diagnosis. This is the first report of the prenatal sonographic diagnosis of Johanson-Blizzard syndrome.

Altered ionic effects of insulin in hypertension: role of basal ion levels in determining cellular responsiveness.

To investigate the ionic actions of insulin in hypertension, 19F- and 31P-nuclear magnetic resonance spectroscopy were used to measure cytosolic free calcium (Ca(i)) and intracellular free magnesium (Mg(i)) levels in red blood cells from normal (n = 9) and hypertensive (n = 9) subjects before and 30, 60, 120, and 180 min after in vitro incubation with insulin. In hypertensive patients, basal Ca(i) levels were significantly higher (30.0 +/- 2.2 vs. 19.8 +/- 2.5 nmol/L; P < 0.05), and basal Mg(i) levels were significantly lower (170 +/- 10.9 vs. 209 +/- 8 micromol/L; P < 0.05) than in normotensive subjects. In normal cells, insulin significantly elevated Ca(i) to 39.8 +/- 8.0, 50.1 +/- 8.2, 69.3 +/- 11.1, and 50.9 +/- 13.4 nmol/L at 30, 60, 120, and 180 min and Mg(i) to 238 +/- 10,264 +/- 14,226 +/- 11, and 216 +/- 10 micromol/L at 30, 60, 120, and 180 min. In hypertensive subjects, the insulin-dependent Ca(i) elevation was blunted, and Mg(i) accumulation was completely suppressed. Continuous relationships were observed between basal values of each ion and insulin responses; the greater the Ca(i), the less the Ca(i) rose (r = -0.574; P = 0.013), and the lower the Mg(i), the less Mg(i) rose (r = 0.524; P = 0.025). Furthermore, a blunting of Mg(i) responses to insulin could be reproduced in normal cells that were magnesium depleted by prior treatment either with A23187 in a calcium-free medium or with high glucose concentrations (15 mmol/L). Once again, insulin responsiveness followed basal Mg(i) levels (r = 0.637; P < 0.001). Together, these data demonstrate ionic aspects of insulin resistance in hypertension and suggest that Ca(i) and Mg(i) levels may regulate cellular responsiveness to insulin. This may help to explain the different vascular actions attributed to insulin in normal compared with insulin-resistant states such as hypertension.

Perinatal cellular ion metabolism: 31P-nuclear magnetic resonance spectroscopic analysis of intracellular free magnesium and pH in maternal and cord blood erythrocytes.

OBJECTIVE: We sought to establish and compare the distribution of intracellular and extracellular magnesium and pH in cord and maternal erythrocytes at the time of delivery. METHODS: We used 31P-nuclear magnetic resonance spectroscopy and a magnesium-specific ion-selective electrode apparatus to evaluate plasma and intracellular red cell content of free magnesium, pH, and ionized calcium in blood obtained from cord and corresponding maternal samples. RESULTS: Cord erythrocyte intracellular free magnesium content (110 +/- 4 mumol/L) and pH (7.02 +/- 0.01) were lower than corresponding maternal intracellular values (140 +/- 9 mumol/L, P < .05; and 7.20 +/- 0.02, P < .0005, respectively). The extracellular cord ionized magnesium concentration in plasma was closely related to the intracellular free magnesium concentration (r = 0.71, P < .005). Extracellular ionized magnesium and calcium were both greater in cord than in maternal samples (P < .05 and P < .0005, respectively). CONCLUSION: These data indicate a differential distribution of extracellular and intracellular magnesium and pH in cord versus maternal blood cells. We hypothesize that these deviations are physiological and may serve to maintain tissue oxygen delivery, while at the same time mediating the changes in vascular tone characteristic of birth.

"Physiologic" intracellular acidosis in pregnancy.

To investigate acid-base homeostasis in pregnancy, we used phosphorus 31 nuclear magnetic resonance spectroscopy to measure intracellular pH in erythrocytes from nonpregnant (n = 33) and third-trimester pregnant women (n = 22). Intracellular pH was lower in pregnant compared with nonpregnant controls (7.23 +/- 0.015 vs 7.29 +/- 0.012, p = 0.003). We hypothesize that this "physiologic" intracellular acidosis of pregnancy potentiates oxygen-hemoglobin dissociation and oxygen delivery across the placenta.

Extracellular and intracellular magnesium depletion in pregnancy and gestational diabetes.

OBJECTIVE: Our purpose was to investigate a possible ionic basis linking pregnancy and gestational diabetes with the vascular disorders associated with them. STUDY DESIGN: We used phosphorus 31 nuclear magnetic resonance spectroscopy and magnesium- and calcium-specific ion electrodes to measure erythrocyte intracellular free magnesium, plasma ionized magnesium, and ionized calcium in fasting nonpregnant (n = 26), normal pregnant (n = 20), and diet-controlled (class A1) gestational diabetic women (n = 13). RESULTS: Compared with nonpregnant controls (total magnesium 0.91 +/- 0.07 mmol/L, ionized magnesium 0.51 +/- 0.03 mmol/L), total and ionized magnesium were significantly lower in both normal pregnant (total magnesium 0.72 +/- 0.07 mmol/L, ionized magnesium 0.46 +/- 0.02 mmol/L, significance < 0.0001) and gestational diabetic (total magnesium 0.74 +/- 0.05 mmol/L, ionized magnesium 0.46 +/- 0.02 mmol/L, significance < 0.0001) subjects. Gestational diabetic women had significantly lower intracellular free magnesium values compared with nonpregnant and normal pregnant individuals (140 +/- 20 mumol/L vs 169 +/- 27 mumol/L, significance = 0.007). Ionized calcium values were similar in all groups, resulting in significant elevation (significance < 0.0001) of ionized calcium/ionized magnesium ratios in both pregnant groups. CONCLUSIONS: These results support the presence of magnesium depletion in pregnancy itself and to a greater extent in gestational diabetes. We suggest that magnesium depletion, or relative calcium excess, may predispose to vascular complications of pregnancy.

Gastroschisis: can antenatal ultrasound predict infant outcomes?

OBJECTIVE: To test previously proposed but unproven antenatal ultrasound prognostic criteria in fetal gastroschisis. METHODS: Thirty consecutive gastroschisis-affected pregnancies and their outcomes were reviewed retrospectively. Data were tabulated by review of antenatal ultrasound videotapes, with blinded comparison to indicators of short- and long-term infant outcomes obtained from the medical records. Criteria of previous reports were applied to these data, focusing on their ability to prognosticate effectively. RESULTS: Applying a criterion of 10 mm bowel dilatation proved minimally useful in prognosticating infant outcomes. However, a stricter 17-mm criterion for clinically important bowel dilatation provided prognostic information, with remarkable improvement in specificity (75 versus 37%) and positive predictive value (55 versus 37%) for infant morbidity, with comparatively little loss of sensitivity (71 versus 85%). CONCLUSIONS: Bowel dilated more than 17 mm on antenatal ultrasound appears to be associated with increased short- and long-term infant morbidity. Whether this finding warrants obstetric intervention in the preterm gastroschisis-affected pregnancy with substantial bowel dilatation remains to be determined.

Risk of anomalies as a function of level of elevated maternal serum alpha-fetoprotein.

OBJECTIVE: Most neural tube defects risks are not actual but mathematical extrapolations. We sought to evaluate this risk and to compare actual performance. STUDY DESIGN: This was a retrospective study of a referral population with elevated maternal serum alpha-fetoprotein results between 1987 and 1992. Ultrasonography results, delivery records, and autopsy results were compared with entry levels of maternal serum alpha-fetoprotein, and the percentage of fetal anomalies detected in this study was evaluated. RESULTS: A total of 773 patients with elevated maternal serum alpha-fetoprotein levels were evaluated. There was a progressive increase in the incidence of anomalies as a direct function of the level of the maternal serum AFP, varying from 3.4% at a level of 2.5 to 40.3% at a level > 7.0. CONCLUSION: Data from this study support the correlation of maternal serum AFP levels with the risk of neural tube defect and ventral wall defects.

Hydrolaparoscopy in the rabbit: a fine model for the development of operative fetoscopy.

OBJECTIVE: Our goal was to become adept at performing laparoscopic procedures within a fluid medium and at using miniature instruments in a small animal model. STUDY DESIGN: Adult female New Zealand rabbits underwent carbon dioxide laparoscopy while they were under general anesthesia with the use of 2 mm instruments. The abdominal cavity was filled with lactated Ringer's solution. Visualization of the intraabdominal organs and surgical procedures were performed below the fluid level. RESULTS: Excellent visualization of the abdominal organs below the fluid level was obtained. Several surgical tasks were accomplished, including cutting and coagulation of the uterine horns with monopolar electrocautery, creation of a defect in the mesovarium and mesometrium, extracorporeal knot tying, and intraabdominal cutting of suture material. Relatively high amounts of energy were needed during electrocautery within the liquid medium (> 25 W). Occasional fluid and gas leakage through the skin punctures was prevented with accessory clamps. CONCLUSION: Hydrolaparoscopy can be performed in the rabbit with miniature instruments. As it simulates the human intraamniotic environment, it is a useful model for the development of operative fetoscopy.

Magnesium is more efficacious than phenytoin in reducing N-methyl-D-aspartate seizures in rats.

OBJECTIVE: Although magnesium sulfate is one of the most commonly used agents for seizure prophylaxis in preeclampsia, its efficacy relative to other anticonvulsants is incompletely investigated. The underlying mechanisms of eclamptic seizures are unknown, and there is currently no universally accepted animal model for eclampsia. However, one commonly used method for studying the relative efficacy of antiepileptic drugs is through their effect on N-methyl-D-aspartate-induced seizures. Our aim was to compare the anticonvulsant effects of phenytoin and magnesium sulfate in an N-methyl-D-aspartate-induced seizure model. STUDY DESIGN: Twenty-one female rats were each stereotaxically implanted with a chronic indwelling bipolar recording electrode in the hippocampus and an injection cannula in the lateral cerebral ventricle. After 7 days animals were randomly given 90 mg/kg magnesium sulfate (n = 7), 50 mg/kg phenytoin, or saline solution (n = 7) intravenously. Fifteen minutes after the infusions animals were given 20 micrograms/microliters N-methyl-D-aspartate by direct intraventricular injection, and seizure activity was assessed for 20 minutes thereafter. All data were analyzed with the Mann-Whitney test. RESULTS: When compared with saline solution controls, total duration of seizure activity in animals treated with magnesium sulfate was significantly decreased (p < 0.05) and time to onset of seizure activity was significantly increased (p < 0.05). However, rats that received phenytoin did not show significant changes in these parameters. The post-N-methyl-D-aspartate seizure mortality rate was 50% in the saline solution controls and 29% in the phenytoin group, whereas none of the rats that received magnesium sulfate died. CONCLUSION: These results suggest that magnesium sulfate is a significantly more effective prophylactic agent than phenytoin for N-methyl-D-aspartate-induced seizures.

Fetal drug therapy.

Fetal drug therapy encompasses several areas, including the prevention of external genital masculinization in 21-hydroxylase deficiency syndrome (congenital adrenal hyperplasia), biochemical amelioration of methylmalonic acidemia, and biotin-responsive multiple carboxylase deficiency. The correction of cardiac arrhythmias has become relatively commonplace, and a reduction in the risks of neural tube defects is now possible with the use of preconceptual and early conceptual folic acid. Similarly, fetal function can be altered by the induction of fetal lung maturity using a number of agents; corticosteroids are the most common fetal pharmaceutic agent, and a number of other agents have also been tried. The most common route of administering pharmaceutic agents is through the mother and the placenta, although the direct administration of certain agents is becoming more common.