Does the Blood-Brain Barrier Integrity Change in Regard to the Onset of Fetal Growth Restriction?

The aim of the study was to determine whether early-onset and late-onset fetal growth restriction (FGR) differentially affects the blood-brain barrier integrity. Furthermore, the purpose of the study was to investigate the relationship between the blood-brain barrier breakdown and neurological disorders in FGR newborns. To evaluate the serum tight junction (TJ) proteins and the placental TJ proteins expression, an ELISA method was used. A significant difference in serum OCLN concentrations was noticed in pregnancies complicated by the early-onset FGR, in relation to the intraventricular hemorrhage (IVH) occurrence in newborns. No significant differences in concentrations of the NR1 subunit of the N-methyl-d-aspartate receptor (NR1), nucleoside diphosphate kinase A (NME1), S100 calcium-binding protein B (S100B), occludin (OCLN), claudin-5 (CLN5), zonula occludens-1 (zo-1), the CLN5/zo-1 ratio, and the placental expression of OCLN, CLN5, claudin-4 (CLN4), zo-1 were noticed between groups. The early-onset FGR was associated with a higher release of NME1 into the maternal circulation in relation to the brain-sparing effect and premature delivery. Additionally, in late-onset FGR, the higher release of the S100B into the maternal serum in regard to fetal distress was observed. Furthermore, there was a higher release of zo-1 into the maternal circulation in relation to newborns' moderate acidosis in late-onset FGR. Blood-brain barrier disintegration is not dependent on pregnancy advancement at the time of FGR diagnosis. NME1 may serve as a biomarker useful in the prediction of fetal circulatory centralization and extremely low birth weight in pregnancies complicated by the early-onset FGR. Moreover, the serum zo-1 concentration may have prognostic value for moderate neonatal acidosis in late-onset FGR pregnancies.

Blood-Brain Barrier Disintegration in Growth-Restricted Fetuses with Brain Sparing Effect.

The endothelial cells of the blood-brain barrier adhere closely, which is provided by tight junctions (TJs). The aim of the study was to assess the damage to the endothelial TJs in pregnancy, complicated by fetal growth restriction (FGR) and circulatory centralization (brain-sparing effect, BS). The serum concentrations of NR1 subunit of the N-methyl-D-aspartate receptor (NR1), nucleoside diphosphate kinase A (NME1), S100 calcium-binding protein B (S100B), occludin (OCLN), claudin-5 (CLN5), and zonula occludens protein - 1 (zo-1), and the placental expressions of OCLN, claudin-4 (CLN4), CLN5, and zo-1 were assessed with ELISA. The significantly higher serum NME1 concentrations and the serum CLN5/zo-1 index were observed in FGR pregnancy with BS, as compared to the FGR group without BS. The FGR newborns with BS were about 20 times more likely to develop an intraventricular hemorrhage (IVH) than the FGR infants without BS. The cerebroplacental ratio (CPR) allowed to predict the IVH in growth-restricted fetuses. The significantly lower placental CLN4 expression was observed in the FGR group with BS and who postnatally developed an IVH, as compared to the growth-restricted infants with BS without IVH signs. Pregnancy complicated by FGR and BS is associated with the destabilization of the fetal blood-brain barrier. The IVH in newborns is reflected in the inhibition of the placental CLN4 expression, which may be a useful marker in the prediction of an IVH among growth-restricted fetuses.

Molecular Indicators of Blood-Brain Barrier Breakdown and Neuronal Injury in Pregnancy Complicated by Fetal Growth Restriction.

This study evaluated the damage to the endothelial tight junctions (TJs) in pregnancies complicated by fetal growth restriction (FGR) and investigated whether FGR is related to blood-brain barrier disintegration and, subsequently, to the appearance of proteins indicative of neuronal injury in maternal blood. The studied group included 90 pregnant women diagnosed with FGR. The control group consisted of 70 women with an uncomplicated pregnancy. The biochemical measurements included serum neuronal proteins (subunit of the N-methyl-D-aspartate receptor-NR1, nucleoside diphosphate kinase A-NME1, and S100 calcium-binding protein B-S100B), serum TJ proteins (occludin-OCLN, claudin-5-CLN5, zonula occludens-zo-1, and OCLN/zo-1 and CLN5/zo-1 ratios), and placental expression of TJ proteins (OCLN, claudin-4 CLN4, CLN5, zo-1). The significantly higher serum S100B and CLN5 levels and serum CLN5/zo-1 ratio were observed in FGR compared to healthy pregnancies. Moreover, FGR was characterized by increased placental CLN5 expression. Both serum NME1 levels and placental CLN4 expression in FGR pregnancies were significantly related to the incidence of neurological disorders in newborns. Mothers of FGR neonates who developed neurological complications and intraventricular hemorrhage (IVH) had statistically higher NME1 concentrations during pregnancy and significantly lower placental CLN4 expression than mothers of FGR neonates without neurological abnormalities. The serum NME1 levels and placental CLN4 expression were predictive markers of IVH in the FGR group. The blood-brain barrier is destabilized in pregnancies complicated by FGR. Neurological disorders, including IVH, are associated with higher serum concentrations of NME1 and the decreased placental expression of CLN4. The serum NME1 levels and placental CLN4 expression may serve as biomarkers, helpful in predicting IVH in FGR. It may allow for more precise monitoring and influence decision-making on the optimal delivery time to avoid developing neurological complications.

Evidence-based guidelines for the management of abnormally invasive placenta: recommendations from the International Society for Abnormally Invasive Placenta.

The worldwide incidence of abnormally invasive placenta is rapidly rising, following the trend of increasing cesarean delivery. It is a heterogeneous condition and has a high maternal morbidity and mortality rate, presenting specific intrapartum challenges. Its rarity makes developing individual expertise difficult for the majority of clinicians. The International Society for Abnormally Invasive Placenta aims to improve clinicians' understanding and skills in managing this difficult condition. By pooling knowledge, experience, and expertise gained within a variety of different healthcare systems, the Society seeks to improve the outcomes for women with abnormally invasive placenta globally. The recommendations presented herewith were reached using a modified Delphi technique and are based on the best available evidence. The evidence base for each is presented using a formal grading system. The topics chosen address the most pertinent questions regarding intrapartum management of abnormally invasive placenta with respect to clinically relevant outcomes, including the following: definition of a center of excellence; requirement for antenatal hospitalization; antenatal optimization of hemoglobin; gestational age for delivery; antenatal corticosteroid administration; use of preoperative cystoscopy, ureteric stents, and prophylactic pelvic arterial balloon catheters; maternal position for surgery; type of skin incision; position of the uterine incision; use of interoperative ultrasound; prophylactic administration of oxytocin; optimal method for intraoperative diagnosis; use of expectant management; adjuvant therapies for expectant management; use of local surgical resection; type of hysterectomy; use of delayed hysterectomy; intraoperative measures to treat life-threatening hemorrhage; and fertility after conservative management.

Uterine arteriovenous malformation - diagnosis and management.

Uterine arteriovenous malformations are uncommon but potentially life-threatening conditions. They can be congenital or acquired and should be suspected in cases of severe or persistent uterine bleeding. In recent years, there has been an in-creasing number of reports of acquired vascular lesions of the uterus following pregnancy, abortion, caesarean delivery and curettage. This paper presents the review of the literature considered epidemiology, pathophysiology, diagnostic methods and treatment options. Unexplained uterine bleeding should be always an indication for colour Doppler ultrasonography and the presence of arteriovenous malformation should be always excluded.

Acquired uterine arteriovenous malformation - a diagnostic dilemma.

Uterine arteriovenous malformations are uncommon but potentially life-threatening condition. They can be congenital or acquired and should be suspected in cases of severe or persistent uterine bleeding. In recent years, there has been an increasing number of reports of acquired vascular lesions of the uterus following pregnancy, abortion, caesarean delivery and curettage. This paper presents the case of unexplained vaginal bleeding with subsequent suspicion and diagnosis of uterine arteriovenous malformation. Unexplained uterine bleeding should be always an indication for colour Doppler ultrasonography and the presence of AVM should be always excluded.

A scoring system predicting the clinical course of CLPB defect based on the foetal and neonatal presentation of 31 patients.

Recently, CLPB deficiency has been shown to cause a genetic syndrome with cataracts, neutropenia, and 3-methylglutaconic aciduria. Surprisingly, the neurological presentation ranges from completely unaffected to patients with virtual absence of development. Muscular hypo- and hypertonia, movement disorder and progressive brain atrophy are frequently reported. We present the foetal, peri- and neonatal features of 31 patients, of which five are previously unreported, using a newly developed clinical severity scoring system rating the clinical, metabolic, imaging and other findings weighted by the age of onset. Our data are illustrated by foetal and neonatal videos. The patients were classified as having a mild (n = 4), moderate (n = 13) or severe (n = 14) disease phenotype. The most striking feature of the severe subtype was the neonatal absence of voluntary movements in combination with ventilator dependency and hyperexcitability. The foetal and neonatal presentation mirrored the course of disease with respect to survival (current median age 17.5 years in the mild group, median age of death 35 days in the severe group), severity and age of onset of all findings evaluated. CLPB deficiency should be considered in neonates with absence of voluntary movements, respiratory insufficiency and swallowing problems, especially if associated with 3-methylglutaconic aciduria, neutropenia and cataracts. Being an important differential diagnosis of hyperekplexia (exaggerated startle responses), we advise performing urinary organic acid analysis, blood cell counts and ophthalmological examination in these patients. The neonatal presentation of CLPB deficiency predicts the course of disease in later life, which is extremely important for counselling.

Prenatal and postnatal detection of congenital heart diseases.

Congenital heart defects are among the most common birth defects and represent a major challenge in prenatal diagnosis and therapy of a newborn.

STUMP - atypowy miesniak macicy - mimikra guza zlosliwego?

This study describes the ultrasound diagnostic process and management in a patient with a unique, rare form of fibroids, i.e. the atypical variant. According to the WHO definition, an atypical uterine myoma cannot be histologically unambiguously diagnosed as benign or malignant. Atypical leiomyomas are characterized by moderate or high quantity of pleomorphic atypical tumor cells, with a small number of mitotic divisions and lack of coagulative necrosis in the tumor. They have a low rate of extrauterine, intraabdominal recurrence, with a negligible risk for distant metastases. Due to the fact the atypical variant of leiomyomas is very rare, it presents a significant diagnostic challenge for obstetricians. The most reliable diagnosis can be made only on the basis of the histopathological examination. In this paper, we present a case of a patient in whom an echo with the diameter of 92 mm and a heterogeneous echogenicity with visible anechoic fields were discovered in the uterine fundus. HD color Doppler demonstrated high vascularization within the tumor, peripherally as well as centrally. The peripheral and central vascularization was rated at 4/4 points on a scale by Exacoustos. The tumor in the uterus met the criteria of high probability of malignancy i.e. 8 points on the vascular scale (power Doppler scale ≥ 7 pts.), solid tumor and a size over 8 cm. Blood flow velocity and vascular resistance in the tumor vessels were evaluated (PSV - 5.76 cm/s, ED - 3.16 cm/s, RI - 0.45 S / D - 1.82). Blood flow in the tumor presented low resistance. Hysterectomy without oophorectomy, with an intraoperative histopathological examination, was performed, and a fibroid was confirmed. The tumor was soft, yellow, with small and medium level of dispersed atypia in microscopic examination. There was no necrosis or mitotic figures. The histopathological image confirmed the atypical leiomyoma of low risk of recurrence. Atypical fibroids are rare in gynecological oncology and they do not have the characteristic clinical course. Furthermore, they do not show the typical characteristics during imaging studies, including ultrasound screening, Sometimes, due to the sonographic image, they should be differentiated from sarcomas. Also, it is necessary to exclude malignancy because of their ambiguous histological characteristics.

Smith-Lemli-Opitz Syndrome- a challenging prenatal diagnosis.

OBJECTIVES: The aim of the study was to present a case of Smith-Lemli-Opitz syndrome (SLOS) in a fetus of a 33-year-old patient. At 31 weeks of gestation, the following fetal malformations were detected on an ultrasound: atrioventricular septal defect (AVSD), aortic coarctation, shortening of the lower limbs, narrow forehead, hyperthelorism, micrognathia, anteverted nares, ambiguous genitalia, and signs of intrauterine growth restriction. The baby died 11 days after birth. Further genetic screening of the parents revealed the 7-DHCR enzyme mutation in both of them. Although the prenatal diagnosis of SLOS presents a challenge due to the fact that little is known about its prenatal phenotype but it may be vital while attempting to treat the fetus in utero.

Pregnancy-dependent blood flow velocity changes in lower extremities veins in venous insufficiency.

INTRODUCTION: Venous insufficiency in pregnancy is associated witch an increased risk of complications. OBJECTIVES: The aim of the study was to analyse the venous system changes of the lower limbs during pregnancy and puerperium with or without venous insufficiency MATERIAL AND METHODS: The research was carried out on pregnant women divided into two groups according to the presence or lack of venous insufficiency The venous system was examined four times: between 11-14th, 18-22nd, 28-32nd gestational week and at the 6th week of puerperium. The doppler examination included the measurement of the blood flow velocity in selected deep veins of the lower limbs: common femoral vein, the superficial femoral vein and the popliteal vein. Consecutively the changes in the blood flow velocity during pregnancy and puerperium were compared between groups and finally to the results obtained in the 1st trimester RESULTS: The analysis of the blood flow showed that the blood flow velocity was statistically lower in the group with venous insufficiency Velocity changes in time showed, in majority of cases, a substantial reduction in the blood flow velocity in the third trimester in both groups. This blood flow velocity increases during the puerperium and does not differ from those observed in the first trimester Thus, the tendency of changes in the blood flow velocity were similar in character in both groups. CONCLUSIONS: The pregnancy related changes in venous system of lower extremities showed the reduction of blood flow velocity with advancing gestational age and were more evident in pregnancy complicated by venous insufficiency

[Placenta percreta--a severe obstetric complication despite correct diagnosis--a case report]. / Lozysko przerosniete--powazne powiklanie poloznicze pomimo prawidlowej diagnozy--opis przypadku.

This paper presents a case of a pregnant woman with a history of two cesarean sections. The patient was admitted to the hospital because of vaginal bleeding. The ultrasound revealed a placenta covering the internal os. The placenta was characterized by heterogeneous echogenicity with visible irregular hypoechogenic areas and blurred border between the placenta and the cervix. Rich vascularity was observed on the border of the placenta, urethra and the urinary bladder. Cystoscopy showed severe congestion around the urethra. On the back wall of the bladder a slightly increased vascularity was seen, which did not allow to confirm or exclude placental ingrowth in the urinary bladder. At 38 weeks, the patient was scheduled for an elective cesarean section. A classic perpendicular incision and leaving the placenta in the uterine cavity were proposed. After opening the abdomen, a strong vascularization in the region of lower part of the uterus and the urinary bladder was seen. Uterine incision in the fundus and the posterior wall was performed. A female fetus (weight: 2950g, Apgar: 10,10) was born. Then, the umbilical cord was ligated with non-absorbable suture and inserted back into the uterus. However, due to the presence of abundant and persistent vaginal bleeding during the next few minutes, conversion to obstetric hysterectomy was required. During relaparotomy fragments of the placenta appeared on the right side after sliding the urinary bladder. The bladder and the left ureter were damaged during surgery. The urinary bladder was sewn after removal of the uterus. Next, the urologist anastomosed end-to-end the left ureter on the pigtail catheter In the third hour of operation, cardiac arrest was caused by ventricular fibrillation. Immediate resuscitation with defibrillation allowed to restore normal function of the cardiovascular system. Total blood loss during the operation was 3000-4000 ml. During surgery 10 units of packed RBCs, 7 units of fresh frozen plasma, and 4 units of cryoprecipitate were transfused. The patient received antibiotics and anticoagulation therapy. Polyuria was diagnosed in the following days of puerperium, accompanied by electrolyte disturbances in serum and urine. The patient was treated with vasopressin and the electrolyte disturbances were corrected. On day 10 postpartum, the urinary catheter was removed, and clear significant improvement and stabilization of renal function and patient health were obtained. The patient was discharged from the hospital on day 19 of the puerperium. In summary it is clear that the steadily increasing rate of cesarean deliveries may result in the future in an increased number of abnormal placentation cases. Abnormal placentation is one of the most important risk factors of severe obstetric complications, including perinatal massive hemorrhage, which can lead to abnormal organ perfusion with cardiac arrest. Therefore, prenatal diagnosis and identification of abnormal placentation are vital in order to plan adequately the date, place, and mode of delivery as well as to ensure the availability of highly qualified specialists in the field of obstetrics and anesthesia, and organize sufficient amount of blood products and blood substitutes.

[The diagnostic algorithm in twin pregnancy]. / Schemat diagnostyczny w ciazy blizniaczej.

This paper presents the diagnostic algorithm in twin pregnancy. The most important sonographic parameters in the assessment of twins have been discussed. Moreover, the most significant complications of twin pregnancy as well as diagnostic possibilities and management, have been also presented and defined.

[Current recommendations for the management of TTTS]. / Aktualne wytyczne dotyczace postepowania w zespole TTTTS.

The paper presents current views and recommendations for pregnancy complicated by TTTS. The symptoms that should attract our attention during the first-trimester ultrasound, i.e. CRL asymmetry NT > 95th percentile, or 20% or more of the NT difference between the fetuses, absent or reversed A wave in DV, and TV regurgitation, are discussed and presented. Similarly symptoms that should attract our attention in the second trimester such as amniotic fluid volume imbalance, asymmetry in the size of the urinary bladders, abdominal circumferences discordance, inter-twin membrane folding, membranous attachment of the donor's umbilical cord, different placental echogenicity and abnormal Doppler measurements, are listed. The paper presents the principle of monitoring based on ultrasound examination, including Doppler studies. The necessity and usefulness of echocardiography is underlined. It is also stressed that the frequency of monitoring depends on the severity of hemodynamic changes and the check-up rate varies from once a week to daily monitoring in extreme cases. This paper presents a variety of therapeutic options, including conservative management, septostomy amnioreduction, laser and selective fetoreduction. Taking into account the level of disease severity stages I and V can be managed conservatively. Fetoscopic laser coagulation of anastomoses, which can be used almost in all stages of TTTS (I-IV), remains to be the treatment of choice. However the current level of evidence does not yet allow us to determine whether laser coagulation increases or reduces the risk of neurodevelopmental delay and mental retardation in children, as compared to other types of therapy. Amnioreduction may be recommended in cases when laser therapy is unavailable or as first-line therapy before transporting the patient to the intrauterine therapy center.

Pulmonary CT angiography in the diagnosis of pulmonary embolism in pregnancy--a case report.

This paper describe the case of pulmonary thromboembolism (PTE) in pregnancy diagnosed by angio CT The clinical diagnosis of PTE in normal population is difficult. In pregnancy is even more complicated, because physiologic changes of pregnancy can mimic signs and symptoms of PTE. Our patient presented dyspnoea, breathing effort and cyanosis of the mouth at admission. In the check-up there was a distinct murmur just under the heart and tachycardia 115 bpm. The Doppler examination of the venous vessels of the lower extremities was normal. Echocardiography revealed features of right ventricular failure. Due to increased level of D-dimers and echocardiographic features of right-ventricular overload, the suspicion of pneumonic embolism was made. Therefore, in order to verify the initial diagnosis the decision of pulmonary CT angiography was made with the radiological protection of the fetus. This study revealed pulmonary embolism in the form of numerous defects in the contrast fillings of the pulmonary arteries. CT pulmonary angiography is the first imaging test of choice in general population who is suspected to have PTE. However there is no consensus what should be preferred during pregnancy. In this paper the diagnostic concepts and an evidence-based guidelines were discussed in case of PTE in pregnancy as well as its side effects including teratogenicity and oncogenicity. In each case, the risks and benefits must be compared before a decision is taken. In case of thrombosis symptoms in the lower extremities, ultrasound should be taken as the next step, otherwise chest X-ray must be performed. In patients with normal chest X-ray the next step should be scintigraphy but if chest X-ray is abnormal, angio CT is preferred.

Retrograde diastolic blood flow in the aortic isthmus is not a simple marker of abnormal fetal outcome in pregnancy complicated by IUGR--a pilot study.

AIM: To evaluate the relation between retrograde diastolic blood flow in the aortic isthmus and adverse perinatal outcome in fetuses with IUGR. MATERIALS AND METHODS: The study included 33 fetuses with IUGR defined as the estimated fetal weight and abdominal circumference under the 10th percentile for a given gestational age. The Doppler examination of the blood flow in the aortic isthmus, umbilical artery umbilical vein, middle cerebral artery uterine arteries and ductus venosus was performed regularly The study population was further divided into two subgroups, depending on the aortic isthmus blood flow direction, i.e. with and without retrograde isthmic diastolic flow. Furthermore, the relation between Doppler blood flow parameters and determinants of the perinatal outcome was analyzed. The perinatal outcome was reported as adverse if any of the following occurred: umbilical cord blood pH < 7,2; 5-minute Apgar score < 7; respiratory distress syndrome, intraventricular hemorrhage (/ll/IV grade); necrotizing enterocolitis; sepsis; intrauterine or neonatal death. RESULTS: There was no statistically significant difference in the incidence of adverse perinatal outcome between the antegrade and retrograde isthmic blood flow groups. Moreover; the study showed no statistically significant relationship between the retrograde blood flow in the aortic isthmus and the prevalence of abnormal flow in the analyzed vessels. CONCLUSION: Retrograde diastolic blood flow in the aortic isthmus presents a low sensitivity and low predictive value in predicting the adverse perinatal outcome in pregnancies complicated with IUGR.

Hypoxia index in the prediction of abnormal CTG at delivery in uncomplicated pregnancies.

OBJECTIVES: The evaluation of hypoxia index (HI) in the prediction of abnormal fetal heart rate at delivery in uncomplicated pregnancies. MATERIAL AND METHODS: The study group included 148 pregnant patients at term (69 patients with and 79 without brain sparing effect). The value of C/U ratio and HI was determined. Next, its value in predicting abnormal fetal heart rate during labor was evaluated. Then the predictive value of the HI index, C/U and last abnormal values of PI and RI in the MCA and the UA were compared in relation to the analyzed parameters. Evaluation included signs of fetal distress in CTG and abnormal fetal outcome. Then selected parameters, characterizing pregnancy course and fetal outcome with abnormal Doppler indices, were compared. RESULTS: The designated value of hypoxia index characterized by abnormal neonatal outcome was >10 for sHI and >14 for HI. Low prognostic value of MCA PI and RI, and UA PI and RI has been shown. The highest predictive value was marked by C/U and HI. There were no statistically significant differences in prediction of abnormal fetal heart rate during labor between C/U ratio, HI and sHI. CONCLUSIONS: The C/U ratio showed the highest sensitivity in the prediction of fetal abnormal heart rate. The C/U ratio, as a easier test, should be recommended as a first-line test in the prediction of abnormal CTG recordings in uncomplicated pregnancies.

Deep endometriosis of the colon.

The article presents a case of deep intestinal endometriosis in a 27-year-old woman who complained of dysmenorrhea and infertility. The diagnostic process included ultrasonography as well as colonoscopy, barium enema and CT imaging. Because of the presence of two distant changes which involved nearly the full thickness of the rectal wall and the major part of its circumference, the decision to perform an anterior rectal resection with a simultaneous retroperitoneal colorectostomy was made. The Knight technique was implemented. The surgery involved the anterior rectal resection, the transverse rectal stump closure by use of a stapling device (TA50), and the creation of colorectal circular anastomosis with the CEEA 31 stapler.

[Definition, classification and diagnosis of chronic venous insufficiency - part II]. / Definicja, podzial oraz diagnostyka przewleklej niewydolnosci zylnej - czesc II.

Venous insufficiency can be defined as a fixed venous outflow disturbance of the limbs. It is caused by the malfunction of the venous system, that may or may not be associated with venous valvular insufficiency and may involve the superficial or deep venous system of the lower limbs, or both. The CEAP scale includes clinical, etiologic, anatomic and pathophysiologic aspects and has been used in the assessment of venous insufficiency Clinical classification comprises of 7 groups. It takes into account the appearance of the skin of the lower limbs, presence of edema, teleangiectasis and varicose ulcers. CLINICAL GRADING: Group C0 - no visible changes in the clinical examination; Group C1 - telangiectasis, reticular veins, redness of the skin around the ankles; Group C2 - varicose veins, Group C3 - the presence of edema without skin changes; Group C4 - lesions dependent of venous diseases (discoloration, blemishes, lipodermatosclerosis); C5 Group - skin changes described above with signs of healed venous ulcers; Group C6 - skin lesions such as in groups C1 to C4 plus active venous ulcers. ETIOLOGICAL CLASSIFICATION INCLUDES: Ec - congenital defects of the venous system, Ep - primary pathological changes of the venous system, without identification of their causes; Es - secondary causes of venous insufficiency of known etiology (post-thrombotic, post-traumatic, etc.). There are many methods of assessing the venous system. One of the most accurate methods is an ascending phlebography which is especially useful in determining detailed anatomy of the venous system, venous patency and identification of perforans veins. The second method may be a descending phlebography useful in determining the venous reflux and morphology of venous valves. Another radiological method is varicography in which the injection of the contrast medium directly into the veins is performed. It is especially useful in the ,,mapping" of venous connections. Trans-uterine phlebography when contrast medium is injected into the bottom of the uterus and its flow is observed, is a very rare test. A similar method is used in a selective phlebography of the ovarian vein and internal iliac vein. This examination is performed when there is a suspicion of connections between varicose veins of the inferior extremities and the pelvis, in case of the occluded iliac and femoral veins. However these tests are highly invasive, causing a lot of discomfort and are connected with numerous complications, particularly the development of venous thromboembolism. An invasive study but not exposing to the emission of ionizing radiation, is a measurement of the marching pressure (known also as ambulatory venous pressure - AVP). Ultrasound Doppler is the "gold standard" in the diagnosis of venous system. Color Doppler technique is irreplaceable due to its non-invasiveness, availability constantly improving of the ultrasound machines and is the method of choice in pregnancy Unfortunately clinical correlation of Doppler ultrasound and thrombosis is bad. Invasive methods, which include various types of phlebographies, have been reserved only for cases of very high diagnostic doubt.

[TAPS sequence--unknown and underestimated problem of monochorionic pregnancies]. / Zespól TAPS--nieznany i niedoceniany problem ciaz jednokosmówkowych.

Monochorionic twin pregnancy is associated with an increased perinatal morbidity and mortality Placental anastomoses are typical for monochorionic pregnancies and may play a role in the development of severe complications such as twin-twin transfusion syndrome (TTTS) and recently discovered twin anemia-polycythemia sequence (TAPS). Both TTTS and TAPS are the chronic form of feto-fetal transfusion. There is a typical oligohydramnios/polyhydramnios sequence in the TTTS syndrome, whereas TAPS is characterized by large inter-twin hemoglobin difference in the absence of amniotic fluid discordances. The paper presents a case of TAPS at 20 weeks of gestation in a 35-year-old primigravida with monochorionic, diamniotic pregnancy TAPS was the cause of Intrauterine fetal death of one of the twins. In the absence of signs of fetal distress an expectant management was considered. An elective cesarean section was performed at 35 weeks of gestation due to decelerations in CTG. This paper presents a clinical case, as well as diagnostic criteria, classification, perinatal management and outcome in TAPS. The review of the literature is also included, focusing on the diagnostic differences between TAPS and TTTS, two distinct variants of feto-fetal transfusion. This case presents a twin anemia-polycythemia sequence, a rare and heterogeneous disease with a wide range of outcome. TAPS may remain undetected during pregnancy and result in the delivery of two healthy neonates with large inter-twin hemoglobin discordance. Unfortunately TAPS may also lead to intrauterine fetal demise of one or both twins, particularly in cases when it is undetected and untreated.