Suspected invasive placenta: evaluation with magnetic resonance imaging.

PURPOSE: To determine the utility of magnetic resonance imaging (MRI) in diagnosing invasive placenta (IP). MATERIALS AND METHODS: MRI findings in 32 women with suspected IP were evaluated independently by four readers. Interobserver agreement was calculated with kappa (κ) statistics. Associations between MRI findings and IP were assessed by univariate and multivariate analyses. Sensitivity, specificity and accuracy of MRI for the diagnosis of IP were estimated. RESULTS: Sixteen women (16/32; 50%) had confirmed IP. Interobserver correlation for the diagnosis of IP was fair (κ = 0.40). Univariate analysis revealed that thinning or focal defect of the uteroplacental interface (P < 0.0001) was the most discriminating MRI variable in the differentiation between normal and IP. Overall sensitivity and specificity of MRI for the diagnosis of IP were 84% [95% CI: 75-94%] and 80% [95% CI: 66-93%], respectively. Thinning or focal defect of the uteroplacental interface was the most accurate finding (88%) in the diagnosis of IP. Multivariate analysis revealed that thinning or focal defect of the uteroplacental interface was the single independent predictor of IP (P = 0.0006; OR = 64.99). CONCLUSION: MR imaging has 84% sensitivity [95% CI: 75-94%] and 80% specificity [95% CI: 66-93%] for the diagnosis of IP. Thinning or focal defect of the uteroplacental interface is the most discriminating independent MR variable in differentiating between normal placenta and IP. KEY POINTS: MR imaging has acceptable degrees of accuracy to diagnose invasive placenta. Focal uteroplacental interface defect is the best finding to diagnose invasive placenta. Focal uteroplacental interface defect is the single independent predictor of invasive placenta.

Postpartum hemorrhage resulting from pelvic pseudoaneurysm: a retrospective analysis of 588 consecutive cases treated by arterial embolization.

OBJECTIVE: This study was designed to determine the incidence of arterial pseudoaneurysm in patients presenting with postpartum hemorrhage (PPH), to analyze the angiographic characteristics of pseudoaneurysms that cause PPH, and to evaluate the effectiveness of pelvic arterial embolization for the treatment of this condition. STUDY DESIGN: Eighteen women with pelvic arterial pseudoaneurysm were retrieved from a series of 588 consecutive patients with PPH treated by arterial embolization. Clinical files, angiographic examinations, and procedure details were reviewed. RESULTS: The incidence of pseudoaneurysm was 3.06 % (18/588; 95 % confidence interval (CI): 1.82-4.8 %). A total of 20 pseudoaneurysms were found; 15/20 (75 %) were located on the uterine arteries. Angiography revealed extravasation of contrast material from pseudoaneurysm indicating rupture in 9 of 18 (50 %) patients. Arterial embolization was performed using gelatin sponge alone in 12 of 18 (67 %) patients or in association with metallic coils in 5 of 18 (28 %) patients or n-butyl-2-cyanoacrylate in 1 of 18 (6 %) patients. Arterial embolization allowed controlling the bleeding in all patients after one or two embolization sessions in 17 of 18 (94 %) and 1 of 18 patients (6 %) respectively, without complications, obviating the need for further surgery. CONCLUSIONS: Pseudoaneurysm is rarely associated with PPH. Arterial embolization is an effective and safe procedure for the treatment of PPH due to uterine or vaginal artery pseudoaneurysm. Our results suggest that gelatin sponge is effective for the treatment of ruptured pseudoaneurysms, although we agree that our series does not contain sufficient material to allow drawing definitive conclusions with respect to the most effective embolic material.

Placental vascularity and resorption delay after conservative management of invasive placenta: MR imaging evaluation.

OBJECTIVES: To assess the potential of magnetic resonance (MR) imaging in evaluating placental vascularity and predicting placental resorption delay after conservative management of invasive placenta. METHODS: MR examinations of 23 women with conservative management of invasive placenta were reviewed. Twelve women had pelvic embolisation because of postpartum haemorrhage (Group 1) and 11 had no embolisation (Group 2). Comparisons between the two groups were made with respect to the delay for complete placental resorption at follow-up MR imaging and degree of placental vascularity 24 h after delivery on early (30s) and late (180 s) phase of dynamic gadolinium chelate-enhanced MR imaging. RESULTS: The median delay for complete placental resorption in the cohort study was 21.1 weeks (range, 1-111 weeks). In Group 1, the median delay for complete placental resorption was shorter than in Group 2 (17 vs 32 weeks) (P = 0.036). Decreased placental vascularity on the early phase was observed in Group 1 by comparison with Group 2 (P = 0.003). Significant correlation was found between the degree of vascularity on early phase of dynamic MR imaging and the delay for complete placental resorption (r = 0.693; P < 0.001). CONCLUSIONS: MR imaging provides useful information after conservative management of invasive placenta and may help predict delay for complete placental resorption.

Conservative two-step procedure including uterine artery embolization with embosphere and surgical myomectomy for the treatment of multiple fibroids: preliminary experience.

OBJECTIVE: To evaluate the feasibility and safety of combined uterine artery embolization (UAE) using embosphere and surgical myomectomy as an alternative to radical hysterectomy in premenopausal women with multiple fibroids. MATERIALS AND METHODS: Mid-term clinical outcome (mean, 25 months) of 12 premenopausal women (mean age, 38 years) with multiple and large symptomatic fibroids who desired to retain their uterus and who were treated using combined UAE and surgical myomectomy were retrospectively analyzed. In all women, UAE alone was contraindicated because of large (>10 cm) or subserosal or submucosal fibroids and myomectomy alone was contraindicated because of too many (>10) fibroids. RESULTS: UAE and surgical myomectomy were successfully performed in all women. Myomectomy was performed using laparoscopy (n=6), open laparotomy (n=3), hysteroscopy (n=2), or laparoscopy and hysteroscopy (n=1). Mean serum hemoglobin level drop was 0.97 g/dL and no blood transfusion was needed. No immediate complications were observed and all women reported resumption of normal menses. During a mean follow-up period of 25 months (range, 14-37 months), complete resolution of initial symptoms along with decrease in uterine volume (mean, 48%) was observed in all women. No further hysterectomy was required in any woman. CONCLUSION: In premenopausal women with multiple fibroids, the two-step procedure is safe and effective alternative to radical hysterectomy, which allows preserving the uterus. Further prospective studies, however, should be done to determine the actual benefit of this combined approach on the incidence of subsequent pregnancies.

Impact of 64-slice coronary CT on the management of patients presenting with acute chest pain: results of a prospective two-centre study.

OBJECTIVE: Our two-centre prospective study evaluates the usefulness of 64-slice coronary computed tomography (CCT) to rule out significant coronary artery stenosis in patients admitted in emergency departments (ED) for acute coronary syndromes (ACS) with low-to-intermediate risk score. METHODS: Patients (175) admitted for acute chest pain (ACP), unmodified electrocardiogram and first troponin measurement within normal ranges were included. A second troponin measurement and a 64-slice CCT within 24 h were performed. Major adverse cardiac events (MACE) were recorded during follow-up (6 months ± 2). RESULTS: 64-slice CCT was either normal or showed non-significant coronary stenosis in the majority of patients (78%). 64-slice CCT depicted significant stenosis (>50% diameter) in 22% of patient whereas initial clinical and biological evaluation was reassuring. For negative CCTs, elevated troponin at second measurement did not modify the strategy or treatment of patients. No MACEs were noted during follow up. In 12% of patients CCT identified unsuspected non-coronary abnormalities. CONCLUSION: Our study confirms 64-slice CCT utility to rule out significant coronary artery stenosis in 8/10 patients admitted in ED with ACP or ACS with low-to-intermediate risk score. Early discharge with a negative 64-slice CCT is associated with very low risk of cardiac events at 6 months. KEY POINTS: • 64-slice coronary computed tomography (CCT) offers a critical role in acute chest pain. • 64-slice CCT allows differentiation between significant and non-significant coronary artery stenosis. • Normal 64-slice CCT allows rapid discharge of patients with ACP. • 64-slice CCT helps make appropriate therapeutic decision in patients with ACP.

Predictive factors of advanced interventional procedures in a multicentre severe postpartum haemorrhage study.

PURPOSE: Severe postpartum haemorrhage (SPPH) is the leading cause of peripartum hysterectomy and maternal death. There are no easily measurable parameters that indicate the failure of medical therapy and the need for an advanced interventional procedure (AIP) to stop genital tract bleeding. The aim of the study was to define factors predictive of the need for an AIP in the management of emergent PPH. METHODS: The study included two phases: (1) an initial retrospective study of 257 consecutive patients with SPPH, allowing the determination of independent predictors of AIP, which were subsequently grouped in a predictive score, followed by (2) a multicentre study of 239 patients admitted during 2007, designed to validate the score. The main outcome measure was the need for an AIP, defined as uterine artery embolization, intraabdominal packing, arterial ligation or hysterectomy. RESULTS: Abnormalities of placental implantation, prothrombin time <50% (or an International Normalized Ratio >1.64), fibrinogen <2 g/l, troponin detectable, and heart rate >115 bpm were independently predictive of the need for an AIP. The SPPH score included each of the five predictive factors with a value of 0 or 1. The greater the SPPH score, the greater the percentage of patients needing an AIP (11% for SPPH 0, to 75% for SPPH ≥2). The AUC of the ROC curve of the SPPH score was 0.80. CONCLUSIONS: We identified five independent predictors of the need for an AIP in patients with SPPH and persistent bleeding. Using these predictors in a single score could be a reliable screening tool in patients at risk of persistent genital tract bleeding and needing an AIP.

Value of pelvic embolization in the management of severe postpartum hemorrhage due to placenta accreta, increta or percreta.

OBJECTIVES: To evaluate the role, efficacy and safety of pelvic embolization in the management of severe postpartum hemorrhage in women with placenta accreta, increta or percreta. METHODS: The clinical files and angiographic examinations of 12 consecutive women with placenta accreta (n=4), increta (n=2) or percreta (n=6) who were treated with pelvic embolization because of severe primary (n=10) or secondary (n=2) postpartum hemorrhage were reviewed. Before embolization, four women had complete placental conservation, four had partial placental conservation, three had an extirpative approach and one had hysterectomy after failed partial conservative approach. RESULTS: In 10 women, pelvic embolization was successful and stopped the bleeding, after one (n=7) or two sessions (n=3). Emergency hysterectomy was needed in two women with persistent bleeding after embolization, both with placenta percreta and bladder involvement first treated by extirpation. One case of regressive hematoma at the puncture site was the single complication of embolization. CONCLUSIONS: In women with severe postpartum hemorrhage due to placenta accreta, increta or percreta, pelvic embolization is effective for stopping the bleeding in most cases, thus allowing uterine conservation and future fertility. Further studies, however, should be done to evaluate the potential of pelvic embolization in women with placenta percreta with bladder involvement.

Differentiation between cavernous hemangiomas and untreated malignant neoplasms of the liver with free-breathing diffusion-weighted MR imaging: comparison with T2-weighted fast spin-echo MR imaging.

OBJECTIVE: To test interobserver variability of ADC measurements and compare the diagnostic performances of free-breathing diffusion-weighted (FBDW) with that of T2-weighted FSE (T2WFSE) MR imaging for differentiating between cavernous hemangiomas and untreated malignant hepatic neoplasms. MATERIALS AND METHODS: Thirty-five patients with cavernous hemangiomas and 35 with untreated hepatic malignant neoplasms had FBDW and T2WFSE MR imaging. Hepatic lesions were characterized with ADC measurement and visual evaluation. Interobserver agreement for ADC measurement was calculated. Association between ADC value and lesion type was assessed using univariate analysis. Sensitivity, specificity and accuracy of ADC values and visual evaluation of MR images for the diagnosis of untreated malignant hepatic neoplasm were compared. RESULTS: ADC measurements showed excellent interobserver correlation (intraclass correlation coefficient=0.980). Malignant neoplasms had lower ADC values than hemangiomas for the two observers (1.11×10(-3) mm2/s±.21×10(-3) vs. 1.77×10(-3) mm2/s±.29×10(-3) for observer 1 and 1.11×10(-3) mm2/s±.19×10(-3) vs. 1.79×10(-3) mm2/s±.32×10(-3) for observer 2) and univariate analysis found significant correlations between lesion type and ADC values. Depending on ADC threshold value, accuracy for the diagnosis of malignant neoplasm varied from 82.9% to 94.3%. Using visual evaluation, FBDW showed better specificity and accuracy than T2WFSE MR images for the diagnosis of malignant neoplasm (97.1% vs. 77.1% and 94.3% vs. 62.9%, respectively). CONCLUSION: FBDW imaging provides reproducible quantitative information and surpasses the value of T2WFSE MR imaging for differentiating between cavernous hemangiomas and untreated malignant hepatic neoplasms.

Preoperative detection of hepatic metastases: comparison of diffusion-weighted, T2-weighted fast spin echo and gadolinium-enhanced MR imaging using surgical and histopathologic findings as standard of reference.

PURPOSE: The purpose of this study was to retrospectively compare the respective sensitivities of diffusion-weighted (DW), T2-weighted fast spin-echo (T2WFSE) and gadolinium chelate-enhanced MR imaging in the preoperative detection of hepatic metastases using intraoperative ultrasonographic and histopathologic findings as the standard of reference. MATERIALS AND METHODS: Twenty-seven patients with 64 surgically and histopathologically proven hepatic metastases had MR imaging of the liver, including DW, T2WFSE and dynamic gadolinium chelate-enhanced MR imaging. Images from each MR sequence were separately analyzed by two readers with disagreements resolved by consensus readings. The findings on MR images were compared with intraoperative ultrasonographic and histopathologic findings on a lesion-by-lesion basis to determine the sensitivity of each MR sequence. Statistical review of the lesion-by-lesion analysis was performed with the McNemar test. RESULTS: DW, T2WFSE and gadolinium chelate-enhanced MR imaging allowed the depiction of 54/64 (84.4%; 95% CI: 73.1-92.2%), 44/64 (68.8%; 95% CI: 55.9-79.8%), and 51/64 (79.7%; 95% CI: 67.8-88.7%) hepatic metastases respectively. DW MR images allowed depiction of significantly more hepatic metastases than did T2WFSE and was equivalent to gadolinium chelate-enhanced MR imaging (P=.002 and P=.375, respectively). CONCLUSION: DW MR imaging is superior to T2WFSE imaging and equivalent to gadolinium chelate-enhanced MR imaging for the preoperative detection of hepatic metastases. Further studies however are needed to determine at what extent DW MR imaging can be used as an alternative to gadolinium chelate-enhanced MR imaging for the preoperative depiction of hepatic metastases.

Persistent postpartum haemorrhage after failed arterial ligation: value of pelvic embolisation.

OBJECTIVES: To evaluate the role and efficacy of pelvic embolisation in the treatment of persistent postpartum haemorrhage after failed arterial ligation and to identify the complications of this procedure in this specific population. METHODS: The clinical files and angiographic examinations of 12 consecutive women (mean age 32 years) who were treated with pelvic embolisation because of persistent, severe postpartum haemorrhage after failed arterial ligation were reviewed. RESULTS: Angiography revealed that persistent bleeding was due to incomplete arterial ligation (n = 4) or the presence of newly developed anastomotic routes (n = 8). In 11 women, pelvic embolisation stopped the bleeding. Hysterectomy was needed in one woman with retained placenta. Two complications due to pelvic embolisation, including leg ischaemia and transient sciatic nerve ischaemia, were identified, both after internal iliac artery ligation. CONCLUSIONS: In women with persistent postpartum haemorrhage after failed arterial ligation, pelvic embolisation is an effective treatment in most cases. However, embolisation of the anastomotic routes that contribute to persistent bleeding may result in ischaemic complications. These potential complications reaffirm that arterial ligation should not be the favoured option for postpartum haemorrhage and that special care must be given during pelvic embolisation after failed arterial ligation.

Suspected anastomotic recurrence of Crohn disease after ileocolic resection: evaluation with CT enteroclysis.

PURPOSE: To determine the utility of computed tomographic (CT) enteroclysis for characterization of the status of the anastomotic site in patients with Crohn disease who had previously undergone ileocolic resection. MATERIALS AND METHODS: Written informed consent was prospectively obtained from all patients, and the institutional review board approved the study protocol. CT enteroclysis findings in 40 patients with Crohn disease who had previously undergone ileocolic resection were evaluated independently by two readers. Endoscopic findings, histopathologic findings, and/or the Crohn disease activity index was the reference standard. Interobserver agreement between the two readers was calculated with kappa statistics. Associations between CT enteroclysis findings and anastomotic site status were assessed at univariate analysis. The sensitivity, specificity, and accuracy of CT enteroclysis, with corresponding 95% confidence intervals (CIs), for the diagnosis of normal versus abnormal anastomosis and the diagnosis of anastomotic recurrence versus fibrostenosis were estimated. RESULTS: Interobserver agreement regarding CT enteroclysis criteria was good to perfect (kappa = 0.72-1.00). At univariate analysis, stratification and anastomotic wall thickening were the two most discriminating variables in the differentiation between normal and abnormal anastomoses (P < .001). Stratification (P < .001) and the comb sign (P = .026) were the two most discriminating variables in the differentiation between anastomotic recurrence and fibrostenosis. In the diagnosis of anastomotic recurrence, severe anastomotic stenosis was the most sensitive finding (95% [20 of 21 patients]; 95% CI: 76.18%, 99.88%), both comb sign and stratification had 95% specificity (18 of 19 patients; 95% CI: 73.97%, 99.87%), and stratification was the most accurate finding (92% [37 of 40 patients]; 95% CI: 79.61%, 98.43%). In the diagnosis of fibrostenosis, both severe anastomotic stenosis and anastomotic wall thickening were 100% sensitive (eight of eight patients; 95% CI: 63.06%, 100.00%), and using an association among five categorical variables, including severe anastomotic stenosis, anastomotic wall thickening with normal or mild mucosal enhancement, absence of comb sign, and absence of fistula, yielded 88% sensitivity (seven of eight patients; 95% CI: 47.35%, 99.68%), 97% specificity (31 of 32 patients; 95% CI: 83.78%, 99.92%), and 95% accuracy (38 of 40 patients; 95% CI: 83.08%, 99.39%). CONCLUSION: CT enteroclysis yields objective and relatively specific morphologic criteria that help differentiate between recurrent disease and fibrostenosis at the anastomotic site after ileocolic resection for Crohn disease. SUPPLEMENTAL MATERIAL: http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.09091165/-/DC1.

Free-breathing diffusion-weighted single-shot echo-planar MR imaging using parallel imaging (GRAPPA 2) and high b value for the detection of primary rectal adenocarcinoma.

Our objective was to determine the diagnostic accuracy of a free-breathing diffusion-weighted single-shot echo-planar magnetic resonance imaging (FBDW-SSEPI) technique with parallel imaging and high diffusion factor value (b = 1000 s/mm2) in the detection of primary rectal adenocarcinomas. Thirty-one patients (14M and 17F; mean age 67 years) with histopathologically proven primary rectal adenocarcinomas and 31 patients without rectal malignancies (14M and 17F; mean age 63.6 years) were examined with FBDW-SSEPI (repetition time (TR/echo time (TE) 3900/91 ms, gradient strength 45 mT/m, acquisition time 2 min) at 1.5 T using generalized autocalibrating partially parallel acquisitions (GRAPPA, acceleration factor 2) and a b value of 1000 s/mm2. Apparent diffusion coefficients (ADCs) of rectal adenocarcinomas and normal rectal wall were measured. FBDW-SSEPI images were evaluated for tumour detection by 2 readers. Sensitivity, specificity, accuracy and Youden score for rectal adenocarcinoma detection were calculated with their 95% confidence intervals (CI) for ADC value measurement and visual image analysis. Rectal adenocarcinomas had significantly lower ADCs (mean 1.036 x 10(-3)+/- 0.107 x 10(-3) mm2/s; median 1.015 x 10(-3) mm2/s; range (0.827-1.239) x 10(-3) mm2/s) compared with the rectal wall of control subjects (mean 1.387 x 10(-3)+/- 0.106 x 10(-3) mm2/s; median 1.385 x 10(-3) mm2/s; range (1.176-1.612) x 10(-3) mm2/s) (p < 0.0001). Using a threshold value < or = 1.240 x 10(-3) mm2/s, all rectal adenocarcinomas were correctly categorized and 100% sensitivity (31/31; 95% CI 95-100%), 94% specificity (31/33; 95% CI 88-100%), 97% accuracy (60/62; 95% CI 92-100%) and Youden index 0.94 were obtained for the diagnosis of rectal adenocarcinoma. FBDW-SSEPI image analysis allowed depiction of all rectal adenocarcinomas but resulted in 2 false-positive findings, yielding 100% sensitivity (31/31; 95% CI 95-100%), 94% specificity (31/33; 95% CI 88-100%), 97% accuracy (60/62; 95% CI 92-100%) and Youden index 0.94 for the diagnosis of primary rectal adenocarcinoma. We can conclude that FBDW-SSEPI using parallel imaging and high b value may be helpful in the detection of primary rectal adenocarcinomas.

Differentiation between true focal liver lesions and pseudolesions in patients with fatty liver: evaluation of helical CT criteria.

OBJECTIVE: To determine the potential of helical CT for differentiating true lesions from pseudolesions in patients with fatty liver. METHODS: Helical CT of 44 patients with diffuse fatty liver (22 with true lesions; 22 with pseudolesions) were reviewed by two observers with regard to morphological features of visible lesions. Univariate analysis was used to detect discriminating criteria for the diagnosis of true lesions. RESULTS: Interobserver agreement was excellent for 9/10 morphological criteria (kappa = 0.831-1). True lesions were more frequently distant from the liver capsule (50.00% vs. 4.55%), located in the right lobe (72.73% vs. 31.82%), round (86.36% vs. 54.55%), heterogeneous (27.27% vs. 0.00%) and had ill-defined margins (40.91% vs. 13.64%) compared with pseudolesions (P < 0.05). Using univariate analysis, a location distant from the liver capsule was the most discriminating variable to differentiate between true and pseudolesions (P = 0.0060). Hyperattenuating content and round shape were the most sensitive criteria (sensitivity = 90.91% and 86.36%, respectively) for the diagnosis of true lesions, and heterogeneity, vascular displacement and encapsulation were the three most specific ones (specificity = 100.00%). Best accuracy was obtained with an association of the three variables (accuracy = 86.36%). CONCLUSION: Helical CT provides objective and discriminating morphological criteria to differentiate between true lesions and pseudolesions in patients with fatty liver.

Crohn's disease: multi-detector row CT-enteroclysis appearance of the appendix.

The objective of our retrospective study was to determine the MDCT-enteroclysis appearance of the appendix in patients with Crohn's disease and to correlate this appearance with the status of the disease. We reviewed the MDCT-enteroclysis examinations of 76 patients with Crohn's disease. Images were analyzed for visualization of the appendix, largest axial diameter of the appendix and degrees of enhancement. Findings were correlated with the status of the disease (active vs. nonactive) and compared with those observed in a control group. Among the various variables, hyperenhancement of the appendiceal wall was found in 18.9% of patients with active disease and in no patients with inactive disease nor in the control group (P = 0.0023). This sign had a specificity of 100% for differentiating between active and inactive Crohn's disease. We conclude that increased appendiceal wall enhancement is, at a statistically significant level, more frequently observed in patients with active Crohn's disease by comparison with patients with inactive disease and control subjects. This result suggests that this finding may be used as an additional MDCT-enteroclysis finding to determine the activity of the disease.

Multi-detector row CT of patients with acute intestinal bleeding: a new perspective using multiplanar and MIP reformations from submillimeter isotropic voxels.

Acute intestinal bleeding is a severe condition, with a mortality rate of up to 40% in case of associated hemodynamic instability. The diagnosis of acute intestinal bleeding is often challenging and to date, there is no definite consensus upon the most appropriate technique for this specific diagnosis. This pictorial essay illustrates our preliminary use of multiplanar (MPR) and maximum intensity projection (MIP) reformations using MDCT scanner with submillimeter and isotropic voxels as an adjunct to axial images in patients with acute intestinal bleeding. MDCT examinations were routinely performed with 64-slice helical CT scanner and images were reconstructed 0.6-mm thickness at 0.5-mm intervals. Multiplanar reconstructions and MIP views were created with a commercially available workstation. Reformatted images from submillimeter isotropic voxels enhanced the depiction of subtle vascular abnormalities and served as a useful adjunct to the axial plane images to improve diagnostic capabilities. Although we are aware that reformatted images should not replace careful analysis of the axial images in patients with acute gastrointestinal bleeding, reformatted images from submillimeter isotropic voxels may clarify the cause of the bleeding, add confidence to image analysis and help interventional radiologists or surgeons improving planning approach.

Cardiac troponin and skeletal muscle oxygenation in severe post-partum haemorrhage.

INTRODUCTION: Cardiac troponin has been shown to be elevated in one-half of the parturients admitted for post-partum haemorrhage. The purpose of the study was to assess whether increased cardiac troponin was associated with a simultaneous alteration in haemoglobin tissue oxygen saturation in peripheral muscles in post-partum haemorrhage. METHODS: Tissue haemoglobin oxygen saturation of thenar eminence muscle (StO2) was measured via near-infrared spectroscopy technology. Two sets of StO2 parameters (both isolated baseline and during forearm ischaemia-reperfusion tests) were collected at two time points: upon intensive care unit admission and prior to intensive care unit discharge. Comparisons were performed using Wilcoxon paired tests, and univariate associations were assessed using logistic regression model and Wald tests. RESULTS: The 42 studied parturients, admitted for post-partum haemorrhage, had clinical and biological signs of severe blood loss. Initial cardiac troponin I was increased in 24/42 parturients (0.43 +/- 0.60 microrg/l). All measured parameters of muscular haemoglobin oxygen saturation, including Srecovery, were also altered at admission and improved together with improved haemodynamics, when bleeding was controlled. Multivariate analysis showed that muscular Srecovery <3%/second at admission was strongly associated with increased cardiac troponin. CONCLUSIONS: Our study confirmed the high incidence of increased cardiac troponin, and demonstrated the simultaneous impairment in the reserve of oxygen delivery to peripheral muscles in parturients admitted for severe post-partum haemorrhage.

CT enteroclysis features of uncomplicated celiac disease: retrospective analysis of 44 patients.

PURPOSE: To describe the computed tomographic (CT) enteroclysis features of uncomplicated celiac disease (CD) and to determine the most indicative appearance of this condition by using a retrospective case-control study. MATERIALS AND METHODS: This study had institutional review board approval. The CT enteroclysis examinations of 44 consecutive patients with proved uncomplicated CD (21 men, 23 women; mean age, 44.45 years) were reviewed by two blinded readers and compared with those obtained in 44 control subjects (21 men, 23 women; mean age, 44.48 years), who were matched for sex and age. Comparisons were calculated by using univariate analysis. RESULTS: Reversed jejunoileal fold pattern had the highest specificity (100%; 44 of 44; 95% confidence interval [CI]: 91.96%, 100%) and was the most discriminating independent variable for the diagnosis of uncomplicated CD (odds ratio, 39.9; P < .0001) but had a sensitivity of 63.64% (28 of 44; 95% CI: 47.77%, 77.59%). Ileal fold thickening, vascular engorgement, and splenic atrophy were other variables that strongly correlated with the presence of uncomplicated CD. CONCLUSION: CT enteroclysis may help establish a diagnosis of uncomplicated CD and may clarify the cause of nonspecific gastrointestinal symptoms in patients with unknown CD. However, future prospective trials are needed to determine the actual value of CT enteroclysis in patients with CD and validate the clinical usefulness of CT enteroclysis in the detection of unknown uncomplicated CD.

Life-threatening intra-abdominal hemorrhage from left superior colonic artery pseudoaneurysm after percutaneous renal biopsy: successful treatment with superselective arterial embolization.

Life-threatening intra-abdominal hemorrhage following ultrasonographically guided percutaneous renal biopsy is extremely rare and, most of the time, is due to renal vascular injury. Injury of other abdominal arteries during percutaneous renal biopsy is exceedingly rare. We report herein a case of left superior colonic artery injury during ultrasonographically guided percutaneous renal biopsy, which was responsible for pseudoaneurysm formation and subsequent intra-abdominal hemorrhage and gastrointestinal bleeding. Arterial pseudoaneurysm was rapidly and successfully treated with minimally invasive endovascular treatment using microcoils. Superselective embolization stopped the bleeding and preserved colonic vascularization, thus preventing ischemia of the involved colonic segment.

Severe primary postpartum hemorrhage due to genital tract laceration after operative vaginal delivery: successful treatment with transcatheter arterial embolization.

The purpose of this study was to report our experience in the management of severe primary postpartum hemorrhage due to genital tract laceration following operative vaginal delivery with forceps using pelvic transcatheter arterial embolization (TAE). Ten women (mean age, 31.9 years) with severe primary postpartum hemorrhage due to genital tract laceration after operative delivery with forceps were treated with TAE. TAE was indicated because of intractable bleeding that could not be controlled with uterotonic drugs, blood transfusion, attempted suturing and packing in all patients. Postdelivery perineal examination showed cervical or vaginal tears in all women and associated paravaginal hematoma in four. Angiography revealed extravasation of contrast material in six patients. TAE performed with gelatin sponge allowed to control the bleeding in all patients. Cervical and vaginal suturing was made possible and successfully achieved in the six women who had failed suturing attempts before TAE. Paravaginal hematoma was successfully evacuated in four patients in whom it was present after TAE. No complications related to TAE were noted. We conclude that in women with severe primary postpartum hemorrhage due to genital tract laceration after operative delivery with forceps, TAE is effective and safe for stopping the bleeding and helps genital tract suturing and evacuation of hematoma.

Abdominopelvic extra-enteric findings at computed tomography enteroclysis: a retrospective evaluation of 430 consecutive patients.

BACKGROUND: Our objective was to retrospectively determine the frequency with which CT enteroclysis (CTE) shows abdominopelvic extra-enteric abnormalities and to analyze how such findings had actually and prospectively affected patient's care. METHODS: The CTE examinations of 430 consecutive patients were retrospectively and blindly reviewed for the presence of possible pathologic conditions that might have affected abdominopelvic organs other than the small bowel. Extra-enteric abnormalities were categorized as negligible or important and correlated with patient's outcome and thus classified as having or not influenced patient's care. RESULTS: Abdominopelvic extra-enteric abnormalities were present on CTE in 258 (60%) of 430 patients. Retrospective analysis of CTE images revealed negligible abnormalities in 217 patients (217/430, 50.5%) and important ones in 41 patients (41/430, 9.5%). Among the 41 patients with important abnormalities, CTE demonstrated already documented abnormalities in 22 patients (22/41, 53.7%) and unknown abnormalities in 19 patients (19/41, 46.3%). In the latter 19 patients, the detection of unknown abnormalities altered patient's care in 18 (94.7%) of them. In one patient (1/19, 5.3%), important abnormality was detected during retrospective evaluation but not prospectively, resulting in a delayed treatment, yielding missed important abnormality rate of 2.4% (1/41). CONCLUSIONS: Abdominopelvic extra-enteric abnormalities are frequent on CTE, but their depictions rarely alter patient's care. However, in a few patients (19/430; 4.4%), CTE may reveal unknown extra-enteric abnormalities that require further evaluation and have substantial impact on patient's management.