[Venous forms of the inborn vascular malformations of the lower extremities. Diagnosis and surgical treatment].

Pathogenetically substantiated approach, using surgical, laser and echosclerosing methods, was applied for improvement of the treatment results in patients, suffering venous forms of the inborn vascular malformations of the lower extremities. The results of examination and treatment in 2006-2009 period were analyzed in 98 patients. The stem malformations with superficial venous system affection was diagnosed in 59 (60.2%) patients, the same with a deep venous system affection--in 27 (27.6%), the extrastem affections--in 7 (7.1%) and the combined malformations--in 5 (5.1%). There was differential tactics of the surgical treatment used together with combination of original surgical procedures, newest laser methods and sclerotherapy, which have permitted to achieve satisfactory late results in 73 (74.5%) patients. Poor results in 25 (25.5%) patients were caused by the pathological process spread and proliferative activity of malformation, what was confirmed by immunohistochemical and morphological investigations data.

Transcutaneous oxygen monitors are reliable indicators of arterial oxygen tension (if used correctly).

The following recommendations should always be kept in mind: Each new transcutaneous equipment, or modification of equipment, must be adequately tested in vivo as well as in vitro. The users must have basic understanding of the principles and the major requirements for applying the tcPO2 technique. Calibration procedures must be carefully adhered to according to the manufacturer's instruction. The temperature of the electrode must be kept at 44 degrees C for premature infants and at 44 degrees or 45 degrees C for term infants if the clinical aim is to estimate arterial PO2 levels. Resetting of the electrode must then be done every two hours. For sick infants, this may be needed more frequently. Whenever there is cause to compare tcPO2 values with arterial ones, the latter must be obtained from an appropriate vessel. Great care must be taken when drawing and analyzing blood for PO2. The infant should not be crying. Significantly lower transcutaneous PO2 values than arterial PO2 values are due to either one or several of the errors indicated above or to an insufficient circulation under the electrode. In recent years, technical or clinical errors seem to have become more and more common. Thereby the technique has unjustly fallen into disrepute. Insufficient circulation under the electrode rarely occurs in the newborn infant and then only in those who are in overt shock.

Transcutaneous PO2 monitoring in routine management of infants and children with cardiorespiratory problems.

Results are reported concerning the clinical application of the transcutaneous PO2 method (tc PO2 method) according to Huch et al. for monitoring arterial PO2. Thirty long-term continuous tc PO2 recordings were made in 22 ventilated children and infants with cardiorespiratory problems in four different pediatric intensive care units (Zürich, Göttingen, Kassel, and Mainz). These recordings were compared with 132 arterial PO2 determinations made during the same period of time. There was a linear relationship and a close correspondence between arterial PO2 and tc PO2 (r = .94). The continuous recordings have shown that the variability of PO2 is much greater than assumed so far by single blood gas analysis. This fact restricts greatly the value of single samples. Continuous tc PO2 monitoring has proved to be a great help in optimal respirator setting.

Lymphocyte beta 2-adrenoceptors and adenosine 3':5'-cyclic monophosphate during and after normal pregnancy.

1. The beta 2-sympathomimetics, used to inhibit preterm labour, bind predominantly to beta 2-adrenoceptors, activating adenylate cyclase to form adenosine 3':5'-cyclic monophosphate (cyclic AMP), a messenger substance which inhibits the enzyme cascade triggering smooth muscle contraction. beta 2-Adrenoceptor density and cyclic AMP formation can be used as markers of beta 2-adrenergic effect. 2. The present study addresses the influence of pregnancy on the beta-adrenoceptor system. beta 2-Adrenoceptor density and cyclic AMP concentrations (basal and evoked by isoprenaline) in circulating lymphocytes were determined at three points in gestation (16, 29 and 37 weeks) and 9 weeks post partum in 22 normal pregnancies. (-)-[125Iodo]-cyanopindolol was used as the ligand to identify a homogeneous population of beta 2-adrenoceptors on lymphocytes. B- and T-cell fractions were estimated from the same samples. 3. beta 2-Adrenoceptor density decreased significantly during gestation until week 37 (P < 0.01), then increased post partum (P < 0.005). Cyclic AMP concentrations (basal and evoked by isoprenaline) were significantly lower after 16 weeks of gestation than post partum (P < 0.05). 4. The results, which cannot be explained in terms of a shift in the lymphocyte (B- and T-cell) ratio, indicate that beta-adrenoceptor density and function are reduced in normal pregnancy and only return to normal post partum. These findings may be of significance in devising future tocolytic therapy with beta 2-adrenoceptor agonists.

Changes in sleep and sleep electroencephalogram during pregnancy.

The impairment of sleep quality is a common complaint during pregnancy. To investigate the changes in sleep in the course of pregnancy, the sleep electroencephalogram (EEG) was recorded and analyzed in nine healthy women on 2 consecutive nights during each trimester of pregnancy. Waking after sleep onset increased from the second (TR2) to the third (TR3) trimester, whereas rapid eye movement (REM) sleep decreased from the first trimester (TR1) to TR2. Spectral analysis of the EEG in nonrapid eye movement (NREM) sleep revealed a progressive reduction of power density in the course of pregnancy. In comparison to TR1, the values in TR2 were significantly lower in the 10.25-11.0-Hz and 14.25-17.0-Hz bands. In TR3, the significant reduction extended over the ranges of 1.25-12.0 Hz and 13.25-16.0 Hz. The largest decrease (30%) occurred in the 14.25-15.0-Hz band. In REM sleep, the spindle frequency range was not affected, and a minor reduction of power density in some frequency bins below 12 Hz was present only in TR3. The study documents major alterations of the sleep EEG that are not evident from the sleep scores and that may be associated with the characteristic hormonal changes occurring during pregnancy.

Lethal multiple pterygium syndrome: suggestion for a consistent pathological workup and review of reported cases.

We report on 2 brothers with lethal multiple pterygium syndrome (LMPS) born to non-consanguineous parents as late spontaneous abortions. Both fetuses presented with massive nuchal edema, and facial anomalies including cleft palate and broad ribs. Apparently, several subgroups of LMPS exist. Differentiation is difficult, as there is no consistent agreement on a workup protocol for autopsies. We compared the findings in the literature on cases with LMPS, and we suggest a standardized workup as an initial step for more efficient differentiation between various subgroups.

Diaphragmatic defects, limb deficiencies, and ossification defects of the skull: a distinctive malformation syndrome.

We report on prenatal and postnatal findings in 4 consecutive fetuses with a pattern of severe congenital anomalies who were born to a healthy nonconsanguineous couple. The spectrum of malformations includes diaphragmatic defects, hypoplastic lungs, omphalocele, limb deficiencies, syndactyly of toes, and ossification defects of the skull. This specific spectrum of anomalies is not fully compatible with that of any established syndrome. No prenatal exposure to any possible teratogen was found. Family history is suggestive for autosomal recessive inheritance, even though germ-line mosaicism in one of the parents cannot completely be excluded.

Ureteral injury after laparoscopic tubal sterilization by bipolar electrocoagulation.

In bipolar electrocoagulation of the fallopian tubes, the electric current is between the tips of the forceps, which are visualized. Therefore, unnoticed burn injuries are uncommon. We describe a case of ureteral stenosis due to inadvertent burn injury, which was successfully managed conservatively.

Blood flow velocity waveforms in human fetal intracranial arteries.

Blood flow velocity waveforms were recorded by pulsed Doppler examination from fetal intracranial arteries in 83 normal and 84 high-risk pregnancies. The normal cases showed a decreasing resistance index of the waveform toward the end of pregnancy, and a continuous forward flow that was always present in these arteries. A low resistance index predicted the birth of a small-for-dates newborn and/or the appearance of subsequent cardiotocographic abnormality, with 57% sensitivity and 94% specificity. Two hydrocephalic fetuses had abnormally high resistance index values. An abnormal fetal intracranial arterial velocity waveform can be seen as a sign of increased perinatal risk.

Recombinant human erythropoietin in the treatment of postpartum anemia.

Postpartum maternal anemia (hemoglobin concentration below 10 g/dL) is a common problem in obstetrics. Human recombinant erythropoietin, which has been shown to correct the anemia of end-stage renal disease and eliminate the need for transfusions, was used in a comparative study of women with postpartum hemoglobin concentrations below 10 g/dL. Five daily doses of 4000 IU were given. Hematologic and clinical data were compared on days 5, 14, and 42 after therapy in the treated women and in untreated women. Both groups received the same iron and folic acid supplements. Significantly greater increases in reticulocytes, hemoglobin, and hematocrit were seen by day 5 for the treated subjects compared with controls. Ferritin levels were significantly lower in the therapy group than in controls. No differences were seen between the groups in the platelet counts or clinical characteristics. No negative side effects were observed. As in other studies in populations without renal disease, recombinant human erythropoietin enhanced endogenous erythropoiesis over and above the normal physiologic recovery rate.

Comparison of continuous transcutaneous Po2 measurement with intermittent arterial Po2 determinations in fetal lambs.

This study determined the validity of transcutaneous Po2 (tcPo2) versus Pao2 determinations in the sheep fetus. In 7 fetal lambs catheters were placed in the carotid artery and the trachea, and ECG leads and a tcPo2 electrode were attached. Intermittently determined Pao2 values were compared to continuously recorded tcPo2 values. Fetal tcPo2 values ranging from 12 to 29 mmHg were achieved by changing the gas mixture the ewe breathed or by inflation of a balloon catheter in the maternal aorta. Transcutaneous Po2 correlated strongly with Pao2 (r = .91). These studies indicate that the tcPo2 electrode precisely and accurately reflects Pao2 in the fetal lamb. Limitations of tcPo2 measurements regarding prolonged attachment of the electrode to the fetal skin as well as fetal skin tolerance to the heat of the electrode have been identified. With this electrode the changes in oxygen tension can be compared with changes in fetal cardiovascular variables, eg, heart rate, blood pressure, and ECG, for a better understanding of the effects of hypoxemia on the fetus.

Effect of epidural anesthesia for cesarean delivery on maternal femoral arterial and venous, uteroplacental, and umbilical blood flow velocities and waveforms.

The effect of epidural anesthesia on the maternal femoral arterial and venous, uteroplacental, and umbilical circulations was studied by the pulsed Doppler technique in 13 women undergoing elective cesarean delivery. Resistance and pulsatility indices of umbilical arterial velocity waveforms did not change with the use of epidural anesthesia. In the uteroplacental circulation, these indices increased in 11 patients, suggesting an increase in resistance. Reduction of sympathetic tone in resistance and capacitance vessels was reflected in the femoral artery by an increase in systolic and end-diastolic velocities, a reversal of the post-systolic backward flow, and an increase in mean velocity. The latter also occurred in the femoral vein. The diameters of these large maternal vessels did not change. This study suggests an impairment in uteroplacental circulation associated with a drop in peripheral vascular resistance and an increase in leg blood flow after epidural anesthesia.

Erythropoietin in obstetrics.

The physiology of maternal and fetal erythropoiesis in pregnancy shows that hematopoiesis, and the stimulation of hematopoiesis, take place separately in the two circulations. Erythropoietin appears the main regulator in both mother and fetus. The human placenta forms a manifest barrier to endogenous and recombinant erythropoietin, thus fulfilling the cardinal precondition for the use of recombinant erythropoietin in the treatment of maternal pregnancy anemia. The prevalence of maternal anemia in pregnancy and post partum is high; up to 95% of cases are due to iron deficiency, compounded post partum by blood loss during and after delivery. Use of rHuEPO for reversing pregnancy and postpartum anemia has given promising initial results.

The neonatal oxycardiorespirogram.

The neonatal oxycardiorespirogram is the simultaneous recording of respiration rate, respiration waveform, instantaneous heart rate, transcutaneous oxygen tension, and relative skin perfusion or "blood flow" from newborn infants. It is important in monitoring the high risk infant to assess the cardiovascular and respiratory function of the patient. The techniques for obtaining the various signals of the oxycardiorespirogram are reviewed and the usual method for making this recording is presented. Several examples of typical oxycardiorespirograms are given.

Fetal and preterm newborn cerebral blood flow velocity.

Using Doppler ultrasound, cerebral blood flow velocities (CBFV) in the first month of life of normoxemic preterm infants born in the 28th gestational week with stable circulatory conditions were examined. The results were compared with fetal CBFV in the 28th to 32nd weeks of pregnancy. Peak systolic (PSV), end-diastolic (EDV) and time averaged maximum velocities (TAMV) were evaluated from the Doppler shifts recorded from the middle cerebral artery (MCA). Cerebral circulatory changes in neonates in the first 4 weeks of life were much more pronounced than in fetuses at the corresponding gestational age (28-32 weeks). After the rapid increase in neonatal CBFV in the first 3 weeks of life, our results appear to indicate a stabilisation between the 3rd and 4th week (corresponding to the 32 gestational weeks). The significance of, and possible mechanisms for, these changes are discussed.

Compression stockings prophylaxis of emergent varicose veins in pregnancy: a prospective randomised controlled study.

QUESTIONS UNDER STUDY: To determine the efficacy of compression stockings in preventing emergent varicose veins in pregnancy. METHODS: A prospective randomised controlled study in the outpatient department of the University Hospital of Zurich, Switzerland, including women with uncomplicated pregnancies <12 weeks at outset of study. A no-stockings control group (n = 15) was compared with two treatment groups: group 1 (n = 12) wore compression class I stockings (18-21 mm Hg) on the left leg and class II stockings (25-32 mm Hg) on the right; in group 2 (n = 15), the compression classes were reversed. Stockings were worn from study entry to term. Endpoints were emergence and worsening of superficial varicose veins, long saphenous vein reflux at the sapheno-femoral junction, and leg symptoms (pain, discomfort, cramps) during pregnancy. RESULTS: Both classes of compression stockings failed to prevent the emergence of superficial varicose veins. However, long saphenous vein reflux at the sapheno-femoral junction was observed in the third trimester in only 1/27 treated women vs. 4/15 controls (p = 0.047); in addition, more treated women reported improved leg symptoms (7/27 vs. 0/15 controls; p = 0.045). Emergent varicose changes, however, did not differ significantly (7/14 controls vs. 5/12 in group 1 and 8/14 in group 2; 3x3 table, Fisher's exact = 0.94). CONCLUSIONS: Although compression stockings do not prevent the emergence of gestational varicose veins, they significantly decrease the incidence of long saphenous vein reflux at the sapheno-femoral junction and improve leg symptoms. Our results also suggest that superficial varices and deep venous insufficiency may have a different aetiology.

No benefit from post-caesarean wound drainage.

AIM OF THE STUDY: A prospective randomized controlled trial to determine the benefit of caesarean wound drainage in 305 low-risk pregnant women. METHODS: Pregnant women at low risk of haemorrhage undergoing caesarean section in the Department of Obstetrics, University Hospital, Zurich, between June 1998 and July 1999 were randomised after informed consent into a no-suction group (n = 154) without post-caesarean wound drainage versus a control group with wound drainage (subfascial and subcutaneous) (n = 151). Outcome measures were perioperative decrease in haemoglobin (Hb), postpartum fever (> 38.5 degrees C for > 2 days), sonographic haematoma and other complications requiring revision, cumulative opiate dose adjusted to body weight, length of hospitalisation and operation time. RESULTS: 305 patients completed the study. Decrease in Hb and the rates of fever, haematoma and revision were similar in both groups. However, cumulative opiate dose was lower in the no-suction group (4.5 +/- 1.8 vs 2.8 +/- 1.4 injections, p = 0.0001), and hospital stay was shorter (6.5 +/- 2.4 vs 7.4 +/- 2.8 days, p = 0.0058), as was operation time (32.7 +/- 11.3 v 36.1 +/- 10.5 min; p = 0.0071). CONCLUSIONS: Routine post-caesarean wound drainage is not only useless but cost-ineffective. In the light of our results, wound drainage may be questioned and should be analysed generally.

Neonatal oxygen-cardiorespirograms.

To those used to intermittent blood sampling, intermittent viewing of ECG, or intermittent counting of heart and respiratory rates, the rapid changes in these variables, as revealed when monitored continuously, must come as a surprise. These rapid changes are found even in quiet, healthy infants. Because of this variability and the diagnostic significance of each single variable, the potential of these variables can be utilized only if they are continuously recorded. It is like studying movement from a videorecording instead of from a couple of photographs taken at different intervals. Knowing normal levels and the trend of changes in all the variables, it becomes easier and more accurate to predict significant clinical changes than before. Or, in M. E. Avery's words, "Those of us who have used continuous monitors would not like to return to the era of sporadic sampling of information."

Guidelines for blood sampling and measurement of pH and blood gas values in obstetrics. Based upon a workshop held in Zurich, Switzerland, March 19, 1993 by an Ad Hoc Committee.

Guidelines for the clinical indications for measuring pH and blood gas values in fetal blood, the procedures of blood sampling and measurement and some reference values for the evaluation of the data are given. They cover: prenatal sampling of blood from the umbilical vessels in conjunction with cordocentesis, intra partum sampling of fetal capillary blood by skin puncture of the presenting part, post partum sampling of blood from a clamped section of the umbilical cord and general analytical techniques.

Maternal and fetal heart rate patterns: a pregnant athlete during training and laboratory exercise tests; a case report.

Maternal and fetal heart rates in a professional athlete were monitored during exercise in pregnancy. No changes were observed in the fetal heart rate following submaximal maternal exertion; however, following strenuous exercise bradycardia was noticed.