Placenta accreta diagnosed at 9 weeks' gestation.

The majority of cases of placenta accreta are unanticipated and initially identified intraoperatively. Although color Doppler ultrasound is adequate for the evaluation of placenta accreta in the third trimester, ultrasound diagnosis in the first trimester has never been reported. To our knowledge, this is the first case of placenta accreta detected at 9 weeks' gestation by ultrasound. Placenta accreta with intraplacental lacunae can be identified together with a loss of the hypoechogenic retroplacental myometrial zone. Based on this case, we found that early diagnosis of placenta accreta in the first trimester by ultrasound is possible.

Isolated tubal torsion managed laparoscopically.

Adnexal cystic lesions in women of reproductive age are common. Most are functional ovarian cysts, followed by paraovarian cysts, hydrosalpinx, and adnexal torsion. A 34-year-old woman experienced mild abdominal pain, nausea, and low-grade fever. She received empiric antibiotics in an outpatient clinic after a diagnosis of tubo-ovarian abscess. After 3 days she was referred to our hospital with no improvement in symptoms or signs. Isolated fallopian tube torsion was diagnosed and successfully treated by laparoscopy. Laparoscopy played an important role in making an accurate diagnosis and avoiding unnecessary delays in treatment.

Prenatal diagnosis and management of congenital cystic adenomatoid malformation.

Congenital cystic adenomatoid malformation (CCAM) is a rare pulmonary malformation resulting from excessive overgrowth of the terminal bronchioles. We present two CCAM case studies: type I (macrocystic) and type III (microcystic), diagnosed by antenatal ultrasonography at 31 and 21 weeks' gestation, respectively. In the former, multiple dilated cystic masses in the fetal left lung, with polyhydramnios, were identified during the antepartum examination. A postnatal thoracotomy with lobectomy was performed due to persistent cyanosis and resulted in a good outcome. In the latter case, an echogenic mass with multiple cysts in the fetal right lung was detected by prenatal sonography. The parents decided to terminate the pregnancy after prenatal counseling.

Relationship between hormone receptor concentration and tumor shrinkage in uterine myoma after treatment with a GnRHa.

BACKGROUND: Uterine myomas are benign tumors of the uterus, occurring in up to 25% of women of reproductive age. We examined the possible causes for different degrees of volume reduction in patients with uterine myomas who received gonadotropin-releasing hormone agonist (GnRHa) treatment by investigating the hormone receptors at the end of GnRHa treatment. METHODS: This trial was designed as a prospective study of five premenopausal women presenting with symptomatic uterine myoma. All patients were treated with a subcutaneous injection of goserelin depot 3.6 mg every four weeks for 16 weeks. Clinical examinations, hormonal evaluation and ultrasound determinations were performed before, during and after treatment. At the end of the treatment period, all patients underwent myomectomy. The concentrations of the unbound progesterone receptors and estrogen receptors were evaluated. RESULTS: The volume of the uterine myoma decreased by 21% to 65%. The percentage of decrease in volume of treated uterine myomas was found to negatively correlate with the concentration of unbound progesterone receptors (r2 = 0.92, p = 0.008). This percentage was not significantly correlated with the concentration of unbound estrogen receptors (r2 = 0.02, p = 0.84). CONCLUSIONS: The limited data available suggested that the volume decrease of uterine myomas in GnRHa-treated patients is partly dependent on the concentrations of unbound sex-hormone receptors in the uterine myomas.

Color Doppler waveforms of maternal cervical internal carotid arteries in normotensive and preeclamptic gravidas.

The objective of this study was to investigate and determine fitted percentiles of blood flow resistance of cervical internal carotid arteries in normal pregnancies from gestational weeks 20 to 42 and to compare the resistance indices and mean velocities of the these arteries in normotensive and preeclamptic gravidas. A duplex color apparatus with pulsed Doppler ultrasound scanner (7.5 MHz) was used to determine the resistance index and mean velocity values of maternal cervical internal carotid arteries in 310 healthy singleton gravidas (group 1) and 74 singleton preeclamptic gravidas (group 2). The resistance index and mean velocity values of the maternal cervical internal carotid arteries decrease as the gestational age increases in normal gravidas, whereas in preeclamptic pregnancies these values are no different from those in normal gravidas during the second half of the gestational period.

Color Doppler ultrasound velocimetry of internal carotid arteries in normal pregnancies.

BACKGROUND: There are few reports on maternal cerebral circulation during pregnancy. Using the hypothesis that cerebral blood flow resistance decreases progressively with advancing gestational age (GA) as a consequence of estrogenic effects on the vascular system during pregnancy, we calculated the pulsatility index (PI) and the mean velocity (MV) of the maternal right internal carotid artery (ICA) in order to build fitted reference centiles. METHODS: A total of 315 pregnant women with a single fetus were studied at 20-42 weeks' gestation. The patients had uncomplicated singleton pregnancies and were without any known fetal or maternal risk factors. Duplex color ultrasound with a pulsed Doppler scanner (7.5 MHz) was used to determine the PI and MV of the maternal ICA. RESULTS: Among the 315 healthy pregnant women, the PI of maternal ICA decreased progressively with advancing GA, PI50th = Exp (0.3124-0.0084 x GA), (p = 0.0003), during the second half of pregnancy. The predicted 50th percentile PI values of the ICA decreased from 1.117 (5th% = 0.755, 95th% = 1.654) at 24 weeks' gestation to 0.917 (5th% = 0.659, 95th% = 1.448) at 40 weeks' gestation. The MV of the maternal ICA also decreased progressively with advancing GA, MV50th = Exp (3.855-0.0093 x GA), (p = 0.0005), during the second half of pregnancy. The predicted 50th percentile MV values in the ICA decreased from 37.811 cm/sec (5th% = 24.177 cm/sec, 95th% = 59.138 cm/sec) at 24 weeks' gestation to 32.591 cm/sec (5th% = 20.818 cm/sec, 95th% = 51.021 cm/sec) at 40 weeks' gestation. CONCLUSIONS: Both the PI and MV of the maternal ICA decreased with GA during the second half of normal pregnancy as a result of intracerebral vessel dilatation.

Color Doppler ultrasound of spiral arteries in normal second-trimester pregnancies.

BACKGROUND: Blood flow resistance of the subplacental spiral arteries in second-trimester pregnancies has not been previously reported. A reference range of blood flow resistance of the subplacental spiral arteries at 13-25 gestational weeks was designed in the hope the reference data could provide a basis for Doppler studies of pathologic disorders in second-trimester pregnancies. METHODS: A cross-sectional study was performed in 175 uncomplicated pregnancies at 13-25 gestational weeks. Doppler flow examinations of the subplacental spiral arteries were done. RESULTS: In the 175 normal pregnancies, both the predicted systolic/diastolic ratios(S/ D) (Y = 1.96258-0.02061x gestational age (GA), adjusted R2 = 0.03773, p = 0.003) and resistance indices (RI) (Y = 0.52131-0.00871 x GA, adjusted R2 = 0.03797, p = 0.003) of the subplacental spiral arteries decreased progressively with advancing gestational age. The predicted S/D value of the subplacental spiral artery decreased from 1.695 at the 13th week's gestation (5th% = 1.221, 95th% = 2.169) to 1.468 at the 24th week's gestation (5th% = 1.057, 95th% = 1.878). The predicted RI value of the subplacental spiral artery also decreased from 0.408 at the 13th week's gestation (5th% = 0.193, 95th% = 0.623) to 0.312 at the 24th week's gestation (5th% = 0.148, 95th% = 0.477). CONCLUSIONS: Normal blood flow resistance of the subplacental spiral arteries at 13-25 gestational weeks decreases progressively with advancing gestational age. The fact suggests that trophoblastic invasion of the spiral arteries occurred continuously throughout normal second-trimester pregnancies.

Color Doppler ultrasound, pregnancy-induced hypertension and small-for-gestational-age fetuses.

OBJECTIVE: The nomogram of blood velocity flow resistance of the spiral arteries was built at 13-25 gestational weeks. Thereafter, by using the nomogram we tried to assess the results of the color Doppler examination of the uteroplacental circulation at the second trimester to predict pregnancy-induced hypertension (PIH) and small-for-gestational-age (SGA). METHODS: Two groups of patients were studied. Group 1, for the establishment of the nomogram, included 175 uncomplicated pregnancies with gestational ages ranging from 13-25 weeks. The Doppler flow waveforms of the spiral arteries were measured once for each pregnancy in the studies. Group 2 consisted of 305 singletons selected consecutively for prospective study to confirm the occurrence of PIH or SGA. They were scanned twice for the measurements of the spiral artery waveforms at 13-19 and 20-25 weeks, respectively to test which gestational weeks interval in the nomogram is most sensitive in predicting PIH and SGA. RESULTS: The 5th, 50th and 95th percentiles of the pulsatility index (PI) values of the nomogram at the second trimester were used as the cut-off points to predict pregnancies complicated with SGA or PIH at delivery. Using the receiver operator curve, the 50th percentiles of the PI values of the nomograms were chosen as predictives for the development of PIH and SGA. At 13-19 gestational weeks, the specificities in predicting PIH and SGA were 50.71% and 49.82%, respectively, and the sensitivities were 52.00% and 50.00%, respectively. The calculated Cohen's Kappa statistics were 0.008 and 0.001, respectively in predicting PIH and SGA. At 20-25 gestational weeks, the specificities in predicting PIH and SGA were 49.64% and 49.46%, respectively, and the sensitivities were 56.00% and 57.14%, respectively. The calculated Cohen's Kappa statistics were 0.017 and 0.022, respectively in predicting PIH and SGA. CONCLUSION: The measurements of uteroplacental blood flow velocity waveforms at the second trimester are not sensitive enough to be an early screening tool for PIH and SGA in the low risk, non-selected pregnancy population. The fact suggests that in most gravidas complicated with PIH and SGA, the physiological process of trophoblastic invasion in the spiral artery was not prevented before the 25th gestational week.

Genetic reassortment in pandemic and interpandemic influenza viruses. A study of 122 viruses infecting humans.

The human influenza pandemics of 1957 and 1968 were caused by reassortant viruses that possessed internal gene segments from avian and human strains. Whether genetic reassortment of human and avian influenza viruses occurs during interpandemic periods and how often humans are infected with such reassortants is not known. To provide this information, we used dot-blot hybridization, partial nucleotide sequencing and subsequent phylogenetic analysis to examine the 6 internal genes of 122 viruses isolated in humans between 1933 and 1992 primarily from Asia, Europe, and the Americas. The internal genes of A/New Jersey/11/76 isolated from a human fatality at Fort Dix, New Jersey in 1976 were found to be of porcine origin. Although none of the geographically and temporally diverse collection of 122 viruses was an avian-human or other reassortant, cognizance was made of the fact that there were two isolates from children from amongst 546 influenza A isolates obtained from The Netherlands from 1989-1994 which were influenza A reassortants containing genes of avian origin, viruses which have infected European pigs since 1983-1985. Thus, genetic reassortment between avian and human influenza strains does occur in the emergence of pandemic and interpandemic influenza A viruses. However, in the interpandemic periods the reassortants have no survival advantage, and the circulating interpandemic influenza viruses in humans do not appear to accumulate avian influenza virus genes.

Selective embryo reduction in multiple pregnancies resulting from assisted conception.

BACKGROUND: Assisted conception not only raises the pregnancy rate by treating infertility, but also increases the chance of obstetrical complication of multiple pregnancy. So it is important to develop a means by which the number of developing embryos can be reduced. METHODS: Eight multiply pregnant women (from triplets to octuplets) asked to have the number of viable fetuses reduced. By means of sonar guided puncture, a mixture of demerol and xylocaine was injected to the fetal thorax until the fetal heart ceased to beat. The procedures were done between the 7th and 11th week of gestational age. Repeated scans were done for three consecutive days to confirm the viability of the remaining fetuses. RESULTS: Except for vanishing twins, no serious complication was noted. For six of the women, 10 healthy births have resulted; the remaining two have ongoing pregnancies. CONCLUSIONS: The procedure described is an easy, safe and effective method to diminish obstetrical morbidity of multiple pregnancy.

Using ultrasonic measurement of cardiac size in predicting congenital heart defect.

A Duplex Color apparatus equipped with real-time imaging and Doppler sector scanner was used to scan fetal hearts, ranging from 17 to 41 weeks gestational age. A total of 323 normal fetuses were studied. The four-chamber view was obtained in a horizontal section just above the level of the fetal diaphragm. Five variables of the Chinese fetal heart in relation to the width of the right ventricle, width of the left ventricle, ratio of right ventricle/left ventricle (RV/LV), length of the fetal heart and the cardiac volume of a four-chamber view were set against gestational age in weeks and expressed in regression equations. The ratio of RV/LV is quite constant in relation to the gestational age. The mean ranges between 0.9916 for 17 weeks gestation and 1.0045 for a term fetus. In 10 abnormal cases with congenital cardiac defects, using the 5th and the 95th percentiles of this normal data as cutoff points, the RV/LV ratio had the highest sensitivity rate of 70% (7/10) in predicting fetal cardiac anomaly. The width of the left ventricle was the second most sensitive parameter with a sensitivity of 4/10 (40%). The RV/LV ratio of a four-chamber view is a simple, time-saving screening parameter for predicting congenital cardiac defects antenatally.