Expression of VEGF in neonatal urinary obstruction: does expression of VEGF predict hydronephrosis?

BACKGROUND: In animal studies, the inhibition of VEGF activity results in high mortality and impaired renal and glomerular development. Mechanical stimuli, like mechanical stretch in respiratory and circulatory systems, results in an elevated expression of VEGF. In animal models, the experimental urinary obstruction is associated with stretching of tubular cells and activations of the renin-angiotensin system. This results in the upregulation of vascular endothelial growth factor (VEGF) and TNF-alfa. MATERIAL/METHODS: Tissue samples from urinary tract obstruction were collected and immunohistochemistry was performed in 14 patients (average age: 7.1±4.1 years). The control histology group consisted of ureteropelvic junction tissue from 10 fetuses after midtrimester artificial abortion. The fetuses did not have any failure at ultrasound screening and pathological examination. The mean gestational age was 20.6 weeks of gestation (±2.2SD). Expression of VEGF was detected with immunohistochemistry method. RESULTS: Expression of VEGF was found in varying intensity in the submucosa and subserosa layers, but only in the test tissue (placental tissue). The tissue of the patients with urinary obstruction and the tissue of the fetal ureteropelvic junction without urinary obstruction were negative for expression of VEGF. The repeated examination showed negative cells and no color staining. CONCLUSIONS: The pressure due to congenital urogenital obstruction resulting in mechanical stress in cells did not increase the expression of VEGF in young children in our study. To find a correlation between urogenital tract obstruction and increased expression of VEGF, we need to perform more examinations because the connection may be of therapeutic significance.

Incidence and causes of maternal thrombocytopenia in triplet gestation.

OBJECTIVE: To determine the incidence, clinical significance and causes of maternal thrombocytopenia in triplet gestations. STUDY DESIGN: The study population consisted of 150 patients with triplet gestation that delivered at our department between 1990 and 2008. Thrombocytopenia was defined as a platelet count <150,000/µL. Patients were classified on the basis of the lowest recorded platelet count observed during pregnancy. RESULTS: A low platelet count was observed during the triplet gestation in 36 cases (24.0%), and after delivery in another 19 cases (12.7%). Thrombocytopenia was mild, moderate, and severe in 75% (27/36), 16.7% (6/36), and 8.3% (3/36) of the cases, respectively. During pregnancy, thrombocytopenia was associated with pregnancy-induced hypertension in 25.0% (9/36) of patients, while gestational thrombocytopenia was diagnosed in 72.2% of the cases (26/36). The mean platelet count showed a strong negative correlation with gestational age (r=-0.953, P<0.001), and at 36 weeks approached the limit of thrombocytopenia. CONCLUSIONS: Thrombocytopenia occurs more frequently in triplet gestations than in the general pregnant population, and the rate of moderate and severe forms is higher. The distribution of causes is comparable to that of the general pregnant population. The average platelet count in triplet gestations decreases with gestational age.

[The maternal and fetal outcome of 122 triplet pregnancies]. / A hármasiker-terhességek anyai és magzati kórjóslata 122 eset alapján.

INTRODUCTION: The wide use of infertility drugs and assisted reproduction has resulted in 4- to 5-fold increase in the incidence of triplet pregnancies, which carry an extremely high risk of maternal complications and adverse perinatal outcome. In Hungary, reduction of multifetal pregnancies is available for all pregnant women with multifetal gestation since 1998. The goal of the procedure is to ensure better outcome for surviving fetuses. Counseling of pregnant patients should include the maternal and fetal risks of triplet gestation without multifetal pregnancy reduction. AIM: To assess the risk of maternal complications, stillbirth, perinatal and neonatal mortality rates, and risk of neonatal morbidity in non-reduced triplets in a large case series, representing the Hungarian triplet population. METHODS: The study population consisted of triplets delivered between July 1st, 1990 and June 30th, 2006, at the 1st Department of Obstetrics and Gynecology. All three fetuses had to be alive on the 18th-week ultrasound scan to be eligible. RESULTS: Out of the 122 cases, 8 (6.6%) ended in midtrimester miscarriage, 114 (93.4%) ended in delivery. There were no maternal deaths. The most common antepartum maternal complications were pregnancy-induced hypertension (16.7%), gestational diabetes mellitus (18.4%), thrombocytopenia (20.2%), anemia (16.7%) and intrahepatic cholestasis (9.7%). Preterm labor requiring tocolysis occurred in 57.9%, preterm premature rupture of membranes in 32.5%. Prophylactic cerclage was performed in 15.8% of cases, and 69.3% of patients received steroid prophylaxis. The mean gestational age at delivery was 32.3 +/- 3.2 weeks. The rates of very early (<28 weeks) and early (<32 weeks) preterm deliveries were 8.8% and 42.1%, respectively. The mean 5-minute Apgar score was 9.2 +/- 0.8, and the mean birth weight at delivery was 1664 +/- 506 g. 38.0% of infants were very low birth weight (<1500 g). Stillbirth, crude perinatal mortality and corrected perinatal mortality rates were 23.4 per thousand, 64.3 per thousand and 27.4 per thousand, respectively. 11.7 per thousand of infants had some major congenital anomaly. 54.4% of infants required ventilation or oxygen therapy or both. The most common neonatal complication were respiratory distress (17.1%), transitory tachypnea (5.2%), sepsis or pneumonia (25.5%), intraventricular hemorrhage (4.3%) and jaundice (11.4%). CONCLUSIONS: Both the maternal and neonatal risks should be considered when patients with triplets are counseled before the decision to continue the triplet gestation or to choose multifetal pregnancy reduction is made.

Characteristic laboratory changes in pregnancies complicated by HELLP syndrome.

INTRODUCTION: HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count) is a severe, life-threatening form of preeclampsia. Its development is accompanied by significant increase in maternal, as well as fetal, morbidity, and mortality rates. It is essential, therefore, for obstetricians to be familiar with the disease. MATERIALS AND METHODS: In the past 10 years, 107 patients were treated for HELLP syndrome in the intensive care unit (ICU) of the First Department of Obstetrics and Gynaecology, Semmelweis University. During this time, we studied the characteristic laboratory findings of the disease from the day of the diagnosis until the first few postpartum days. RESULTS: HELLP syndrome was present in 0.37% of all women having live births. In our study, the liver enzymes AST, and LDH, and the level of total bilirubin (indicating the degree of hemolysis), and repeated thrombocyte counts were suitable for following the cases. The AST, LDH and bilirubin levels returned to normal between the third and seventh days postpartum. The platelet count passed the critical level of 100,000/microL on the third to fourth day. CONCLUSIONS: We have found that the platelet count, LDH, AST, and total bilirubin levels proved to be useful indicators of the progression of HELLP syndrome.

[Maternal age as a risk factor in triplet pregnancy]. / Az anyai életkor mint kockázati tényezo hármasiker-terhességben.

UNLABELLED: Upon the diagnosis of triplet conception, pregnant women should be counseled about the risk of triplet pregnancy and the chances of survival of triplet newborns. This information can help women with triplet gestations to make well-informed decisions whether to continue their pregnancy or to undergo multifetal pregnancy reduction. AIM: To assess the maternal age as a risk factor in a large representative sample of the Hungarian triplet population with evaluation of maternal complications and perinatal results. METHODS: In a retrospective cohort study we analyzed 114 triplet pregnancies which ended in delivery from July 1st, 1990 until June 30th, 2006. RESULTS: In the study population there were 15 patients aged 35 years or more at delivery (13.2%) and 99 women were younger than 35 years (86.8%). The rate of maternal complications was similar in the two groups, and there was no significant difference in gestational age at delivery (33.0 +/- 2.9 vs. 32.2 +/- 3.3 weeks), very early (< 28 weeks) premature deliveries (6.7% vs. 9.1%) and early (< 32 weeks) premature deliveries (32.9% vs. 43.4%), respectively, although all of these variables were more favorable over 35 years of age. The mean birth weight of live born infants (1796 +/- 492 vs. 1664 +/- 506 g, p = 0.064 g) was higher, the prevalence of very-very-low-birth-weight (< 1000 g) infants (6.8% vs. 10.7%) and very-low-birth-weight (< 1500 g) infants (34.1% vs. 38.6%) was lower in the groups of older patients. The 1- and 5-minute Apgar scores of newborns in the > 35-year group were significantly larger (8.4 +/- 0.5 vs. 8.0 +/- 1.0, p = 0.016 and 9.5 +/- 0.7 vs. 9.2 +/- 0.8, p = 0.006, respectively). There was no difference in perinatal results or puerperal complications between the groups. The incidence of sepsis/pneumonia and need for ventilation/oxygen therapy was lower among the infants of the patients over 35 years (6.9% vs. 28.6%, p = 0,011 and 31.0% vs. 58.2%, p = 0,011, respectively). The rate of other neonatal complications was similar in the two groups. CONCLUSIONS: Although the incidence of some maternal complications during pregnancy and in the puerperal period is higher at older age, the favorable perinatal results and neonatal morbidity rates make older maternal age a risk reducing (protective) factor in triplet pregnancies.

[Assessment of serum interleukin-6 with a rapid test. The diagnosis of neonatal sepsis can be established or ruled out]. / Szérum-interleukin-6-meghatározás gyorsteszt segítségével. Az újszülöttkori szepszis korai diagnózisa, kizárása.

INTRODUCTION: The mortality rate from sepsis is high and the risk of sepsis increases in prematurity in proportion to the decrease in birth weight. MATERIAL AND METHOD: The authors report the assessment of serum interleukin-6 levels in 12 term, at-risk newborn infants after birth and 60 VLBW neonates after detection of non-specific signs of infection or sepsis, treated in NICU at the Semmelweis University, 1st Department of Obstetrics and Gynecology in 2005-2006. The serum IL-6 level with a rapid test (Milenia Quickline IL-6 and PicoScan system) was investigated. The simultaneous assessment of C-reactive protein levels was analysed as well. RESULTS: The assessment of serum interleukin-6 and CRP levels for the early diagnosis of sepsis can be established or ruled out. The sensitivity of serum IL-6 level assessment was 100%. There were no false negative cases. The positive predictive value was 93%. There was a significant difference between the sepsis and infection group of VLBW infants in the serum Il-6 levels ( p = 0.048), and between the infection and non-infection groups in the interleukin-6 levels ( p < 0.005). CONCLUSIONS: In comparing the diagnostic value of IL-6 measurement in VLBW infants with signs of infection to the diagnostic methods currently in use, results showed that a combination of early assessment of IL-6 and CRP seems to increase diagnostic accuracy in attempting to differentiate between septic and nonseptic patients. Such increased accuracy will decrease neonatal morbidity as well as the financial cost of treatment.

[The rate of maternal complications in 107 pregnancies complicated with HELLP syndrome]. / Anyai szövodmények elofordulása 107 HELLP-szindrómával szövodött terhesség kapcsán.

INTRODUCTION: HELLP syndrome (Haemolysis, Elevated Liver enzymes, Low platelet count) is a grave, life threatening form of preeclampsia, which was named by Weinstein in 1982, on the basis of characteristic changes in laboratory findings (haemolysis, elevated level of liver enzymes and thrombocytopenia). OBJECTIVE OF THE STUDY: To assess the rate of maternal complications in HELLP syndrome. MATERIAL AND METHODS: In the past ten years, 107 patients were treated for HELLP syndrome at the Intensive Care Unit (ICU) of the 1st Department of Obstetrics and Gynaecology, Semmelweis University. The authors summed up about their experience with the treatment of patients, with special regard to the typical symptoms of HELLP syndrome, the course of the disease, postpartum maternal complications. RESULTS: The frequency of HELLP syndrome in live births was found to be 0.37%. In 96% of the patients the pregnancy was terminated via Caesarean section. Pulmonary oedema was the most common cardiopulmonary complication (11%) and developed in Mississippi Group I in the majority of the cases (21%). Transfusions had to be given quite frequently; 62% of the patients in the study were transfused using erythrocyte preparations. In persistent or progressive cases in the postpartum period, the elimination (uterine curettage and lavage) of factors responsible for the persistence of the disease (toxic and vasoactive agents in the endometrium) resulted in the recovery of one third of the patients. Maternal thromboembolic complications developed in 11% of the patients, each of them was affected in Mississippi Group I, with the lowest platelet count. CONCLUSIONS: The immediate termination of a pregnancy in which HELLP syndrome emerges may save the patient's life. It is recommended to try and lift foci applying uterine curettage and lavage as the first step, if the mothers' condition persists or progresses after delivery. Its development is accompanied by a significant increase in maternal and fetal morbidity and mortality alike, therefore it is essential for the obstetricians to be familiar with the disease.

[The outcome of triplet pregnancies at the First Department of Obstetrics and Gynecology, Semmelweis University, in the last 15 years]. / Hármas ikerterhességek kimenetele a Semmelweis Egyetem I. Szülészeti és Nôgyógyászati Klinikáján az elmúlt 15 év alatt.

INTRODUCTION AND METHODS: The authors analysed the data of 307 live-birth newborns and premature infants who were born from 104 triplet pregnancies between 1 January 1990 and 31 December 2005 at the Semmelweis University First Department of Obstetrics and Gynecology. AIMS AND RESULTS: In 86% of the triplet pregnancies conception took place with the help of assisted reproduction technology, the number of which has rapidly increased in the last 15 years. 60% of the triplet pregnancies ended before the 34th week of gestation and the birth weight of more than one third of the infants was less than 1,500 grams. Among the infants treated in the Neonatal Intensive Care Unit the most common diagnosis was connatal pneumonia, which was followed by hyaline membrane disease due to the low birth weight. In the past 15 years, the mortality of triplets was at 6.5%. The birth weight of those who died before reaching the age of six months was, with two exception cases, below 1500 grams. CONCLUSION: According to our data the chance of survival of triplets was poorer in category of birth weight under 1000 grams than those of premature infants born of single pregnancies with the same weight. In vitro fertilisation in the case of triplets increases the occurrence of premature deliveries and the number of infants with very low weight. Long-term monitoring data reveals that in such cases, neurological lesions and the occurrence of a chronic disease, which greatly influences the future quality of life for the child as well as for its family, is more frequent between the very low birth weight infants.

[Congenital heart malformations is twin pregnancies]. / Szívfejlodési rendellenességek ikerterhességekben.

INTRODUCTION: In twin pregnancies the risk for congenital heart malformation is higher than in singular pregnancies. Because of the development of prenatal diagnostic methods, it is possible to recognise congenital malformations. In point of view of congenital cardiac malformations the twin pregnancies belong to high risk group. AIM: To found connection between congenital heart malformations and twin pregnancies. MATERIAL AND METHOD: Retrospective analysis of data of Fetal Cardiology database between 1. january 1966 and 30. november 2003. RESULTS: In singular pregnancies 455, and in twin pregnancies 31 severe congenital heart malformations were diagnosed prenatally. It means, that congenital heart malformations were diagnosed prenatally in 2% of singular pregnancies and in 4,6% of twin pregnancies. In monozygotic twin pregnancies in 36% of heart malformations were pulmonary stenosis and in 45% endocardial fibroelastosis. In dizygotic twin pregnancies Ebstein malformation was more common than it statistically expected. In dichorial and dizygotic twin pregnancies the cardiac malformations were similar to in singular pregnancies. CONCLUSIONS: In twin pregnancies the rate of congenital heart malformations is higher than in singular pregnancies, that's why the twin pregnancy is indication for fetal echocardiography. In monochorial twin pregnancies different types of congenital heart malformations are expected than in singular or dichorial twin pregnancies, the chorionicity seems more important than the zygosity.

[Pathophysiology and therapeutic possibilities in twin-to-twin transfusion syndrome]. / Az iker-iker transzfúzió szindróma kórtana és terápiás lehetóségei.

INTRODUCTION: Twin-to-twin transfusion syndrome is a threatening consequence of monochorionicity. Without therapeutic intervention it has approximately a 100% mortality rate, but due to therapeutic efforts it improved dramatically to about 20-50% mortality. It is caused by arteriovenosus anastomoses within the placenta, that causes hormonal changes, polyhydramnios, hypertension of the recipient and weight discordance. AIMS: Detection of ultrasonographic and pathologic consequences of twin-to-twin transfusion syndrome. PATIENTS AND METHODS: Ultrasonographic and pathologic findings of six twin pairs were analysed with the common feature of twin-to-twin transfusion syndrome. RESULTS: Ultrasonographic and pathologic results were suggestive for fetal hypertension in all recipients and pulmonary stenosis in four of them. CONCLUSION: The prognosis of twin-to-twin transfusion syndrome can be improved significantly with serial amnioreduction, amniotic fenestration, laser ablation of connecting vessels or selective fetocidium. Proper therapy prevents the development of the serious clinical and pathological consequences of twin-to-twin transfusion syndrome.

Intrauterine left chamber myocardial infarction of the heart and hydrops fetalis in the recipient fetus due to twin-to-twin transfusion syndrome.

A rare complication of twin-to-twin transfusion syndrome (TTTS) is described: myocardial infarction of the recipient fetus. Myocardial infarction and hydrops are considered to be consequences of hypertension in the recipient. No other organs were affected. Pathological signs of intrauterine hypertension were estimated by the thickness of vessel walls and signs of hypertrophied myocardial cells. In the heart of the recipient fetus there was a chronic myocardial infarction near the apex cordis on the anterior wall with an aneurysm 4x5 mm in diameter. Diagnosis was based on light microscopic examination. The poor myocardial systolic function resulted in hydrops. Since the mother was administered beta sympathomimetics in therapeutic doses the contribution of the drug to the myocardial infarction is uncertain, but we would like to suggest this as a possible adverse effect in TTTS. The present case is the first reported myocardial infarction in connection with the syndrome.