[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.

Cross sectional study of automated blood pressure measurements throughout pregnancy.

OBJECTIVE: To generate reliable new reference ranges for pregnancy blood pressure from a large population. DESIGN: A prospective cross sectional study. SETTING: Obstetric outpatient clinic, Zurich University Hospital. SAMPLE: Accurately dateable singleton pregnancies (Caucasian: n= 3234; Asian [predominantly from Sri Lanka, Thailand and the Philippines]: n= 577; Black n= 212). METHODS: Between January 1996 and February 2000 blood pressure was determined in 4023 pregnant women using an oscillometric automated device (Dinamap) according to British Hypertension Society recommendations. Women receiving antihypertensive medication were excluded. MAIN OUTCOME MEASURE: Blood pressure. RESULTS: Only the means of duplicate measures at the booking visit (5-42 weeks) were used in the analysis. Mean blood pressure decreased from early to mid pregnancy before increasing to levels 4 mmHg higher at term than in early pregnancy. Values >130/80 and <90/50 mmHg were above the 95th and below the 5th centiles, respectively. Parity, age and body mass index were significant determinants in Caucasians. Blood pressure was slightly lower in Asians and Blacks. CONCLUSIONS: The current World Health Organisation definition of high diastolic blood pressure (>or=90 mmHg on two occasions) reflects values >2 standard deviations from the mean. This may be too conservative as threshold for detecting women at risk of pre-eclampsia. Further studies are required to determine the prognostic implications of gestational values >or=95th centile (>or=130/80 mmHg) and

[Specific aspects of regional hemodynamics in patients with ischemic foot contracture based on ultrasonic investigation data]. / Osoblyvosti rehionarnoï hemodynamyky u khvorykh z ishemichnoiu kontrakturoiu stopy za danymy ul'trazvukovoho doslidzhennia.

In 20 patients with ischemic contracture of foot (ICF) the ultrasonic investigation (UI) results of peripheral blood flow of lower extremity were analyzed. The functional test was applied for differentiation of hypoperfusion and functional state of lower extremity vessels. According to UI data the blood flow in peripheral arteries in patients was characterized by an ischemic changes of different degree, most pronounced in patients with inveterate damages of popliteal artery. Increase of humero-malleolar index on the damaged extremity in patients with ICF was revealed for the first time.

Hypertension in a pregnancy with renal anemia after recombinant human erythropoietin (rhEPO) therapy.

Management of renal anemia in pregnancy remains a major issue. We report the use of human recombinant erythropoietin (rhEPO) combined with parenteral iron sucrose in a pregnancy with chronic glomerulonephritis, progressive anemia and initially normal blood pressure. Therapy from 32 weeks gestation increased the hematocrit by 0.4% daily and the hemoglobin from 8.6 to 10.3 g/dL within 2 weeks. Despite the improvement of anemia, Cesarean section had to be performed at 34 weeks due to acute hypertension, preeclampsia and worsening renal function. Blood pressure remained elevated postpartum. Because of symptomatic postpartum anemia with a hemoglobin of 7.5 g/dL on the 5th postoperative day rhEPO in combination with parenteral iron sucrose was readministered over 3 following days. Blood pressure reached a maximum of 210/130 mm Hg 3 weeks later. Possible causes include advancing preeclampsia and renal disease, but also rhEPO (due to its intrinsic vascular effects and/or the rapid response of the hematocrit), and a combination of both.

Parenteral iron therapy in obstetrics: 8 years experience with iron-sucrose complex.

Fe is an essential component of haem in myoglobin and accounts for 70 % of haemoglobin. The balance of Fe, unlike that of other metals such as Na or Ca, is regulated solely by gastrointestinal absorption, which itself depends on the bioavailability of Fe in food, i.e. the chemical Fe species. Factors that maintain Fe homeostasis by modulating Fe transfer through the intestinal mucosa are found at the luminal, mucosal and systemic levels. Fe deficiency and its consequence, Fe-deficiency anaemia, form the commonest nutritional pathology in pregnant women. The current gold standard to detect Fe deficiency remains the serum ferritin value. Previously there was general consensus against parenteral Fe administration, i.e. parenteral Fe was only recommended for special conditions such as unresponsiveness to oral Fe, intolerance to oral Fe, severe anaemia, lack of time for therapy etc. However, especially in hospital settings, clinicians regularly face these conditions but are still worried about reactions that were described using Fe preparations such as Fe-dextrans. A widely used and safe alternative is the Fe-sucrose complex, which has become of major interest to prevent functional Fe deficiency after use of recombinant erythropoietin Numerous reports show the effectiveness and safety of the Fe-sucrose complex. Good tolerance to this Fe formulation is partly due to the low allergenic effect of the sucrose complex, partly due to slow release of elementary Fe from the complex. Accumulation of Fe-sucrose in parenchyma of organs is low compared with Fe-dextrans or Fe-gluconate, while incorporation into the bone marrow for erythropoiesis is considerably faster. Oral Fe is only started if haemoglobin levels are below 110 g/l. If levels fall below 100 g/l or are below 100 g/l at time of diagnosis, parenteral Fe-sucrose is used primarily. In cases of severe anaemia (haemoglobin <90 g/l) or non-response to parenteral Fe after 2 weeks, recombinant erythropoietin is considered in combination. By using parenteral Fe-sucrose in cases of severe Fe deficiency, anaemia during pregnancy is treated efficiently and safely according to our results and rate of blood transfusion could be reduced considerably to below 1 % of patients per year.

Diagnosis of skeletal dysplasia by multidisciplinary assessment: a report of two cases of thanatophoric dysplasia.

Skeletal dysplasias, a heterogeneous group of bone growth disorders, can be detected by routine prenatal ultrasound examination. As it is difficult to make a specific diagnosis, prediction of prognosis is of importance for obstetric management. In order to specify diagnosis, radiological, pathological and molecular genetic examination are often required. Our report describes two cases of thanatophoric dysplasia with different fetal sonographic findings. The classical classification of type I and II seems to be ambiguous as, in both cases, the same mutation in the fibroblast growth factor receptor 3 gene was found. The importance of comprehensive multidisciplinary assessment is emphasized.

Excretion of low molecular weight heparin in human milk.

AIMS: The excretion of low molecular weight heparin (LMWH) in breast milk was investigated in 15 lactating mothers after Caesarean section. METHODS: Blood and milk samples were collected before and 3-4 h after once daily routine subcutaneous injection of 2500 IU dalteparin. Anti-Xa activity was measured by an assay utilizing prolonged clotting times in plasma or breast milk as an index of LMWH activity. RESULTS: Plasma anti-Xa activities ranged from 0.074 to 0.308 IU ml(-1) of plasma. Anti-Xa activities in breast milk ranged from < 0.005-0.037 IU ml(-1) of milk. This is equivalent to a milk/plasma ratio of < 0.025-0.224. CONCLUSIONS: Therefore, it appears highly unlikely that puerperal thromboprophylaxis with LMWH has any clinically relevant effect on the nursing infant.

Pregnancy-associated recurrent hemolytic uremic syndrome with fetal thrombotic vasculopathy in the placenta.

A case report of hemolytic uremic syndrome with placental involvement in 2 of 3 consecutive pregnancies highlights the impact on the fetal placental compartment and the importance of diligent antenatal care in subsequent pregnancies.

[Quality of praenatal diagnostic ultrasound - comparison of sonographically detected foetal anomalies with diagnostic findings verified post-partum in Switzerland]. / Qualität der pränatalen sonographischen Diagnostik - Vergleich sonographisch erfasster Fehlbildungen mit dem tatsächlichen fetalen Outcome in der Schweiz.

AIM: Comparison of all praenatally detected cases of foetal anomalies to actual diagnostic findings post partum during a one year period in Switzerland. METHODS: A retrospective questionnaire-based evaluation including the 5 university hospitals and 6 large hospitals in Switzerland as a population-based study. Analysis of all foetal anomalies detected praenatally by ultrasound in the year of 1995 in these centres. RESULTS: 347 cases have been included in the study. 89 % of cases were detected using screening methods. (2/3) were referred by obstetrical practitioners and GPs. 62 % of the pregnancies were completed and 33 % terminated, while the rest resulted in abortion or stillbirth. In terminated pregnancies there was a 82 % agreement between praenatal and postmortem findings. Sonographic results and clinical/post-mortem diagnosis were in agreement about the presence of major foetal anomalies in 18 % of cases. Additional minor anomalies unperceived by sonography, however, were seen post mortem. There was no false positive case. CONCLUSIONS: Without ultrasound screening almost 90 % of anomalies would have been missed due to the absence of clinical symptoms. The Swiss two-step system for praenatal ultrasound screening, based on screening scans done by the obstetrician and GP in practice, or residents in the public outpatient clinics respectively, and the detailed scan done by a subspecialized perinatologist shows excellent results especially in the subgroup of terminated pregnancies.

The relationship between cervical dilatation, interleukin-6 and interleukin-8 during term labor.

BACKGROUND: To determine interleukin-6 and interleukin-8 levels in amniotic fluid, retroplacental blood and maternal serum and relate these values with cervical dilatation in term labor. METHODS: Prospective study. n=78 healthy women undergoing term cesarean section, divided into four groups: controls, n=42, (elective cesarean section; no contractions, membrane rupture or cervical dilatation); latent labor, n=12, (latent phase labor; cervix <2 cm dilated); established labor, n=12, (active labor, cervix 2-5 cm); advanced labor, n=12, (active labor, cervix >5 cm). Interleukin-6 and interleukin-8 were determined by ELISA (pg/ml), placenta and placental bed biopsy examined histopathologically, and amniotic fluid also microbiologically. Results were expressed as median and ranges or mean and standard deviations, as appropriate. For statistical analysis, Mann-Whitney U-tests or Kruskal-Wallis tests were used as applicable (Statview 4.5). Power and linear regression analyses were performed. p<0.05 was considered significant, p<0.001 highly significant. RESULTS: Compared with controls, IL-6 and IL-8 increased significantly with cervical dilatation in all compartments tested for almost all labor groups (p<0.05 to p<0.0001). Significant changes were also seen between latent and advanced labor groups in some compartments (p<0.05), but not between established and advanced labor groups. Intrauterine infection was excluded in any of the patients clinically and on histopathological or microbiological analysis of placentae and amniotic fluid. CONCLUSIONS: In term labor without intraamniotic infection, interleukin-6 and interleukin-8 at the fetomaternal interface and in maternal serum rise significantly with cervical dilatation. These cytokines could be used as markers of active labor if vaginal examination is not applicable.

[Two-stage delivery after spontaneous rupture of fetal membranes and delayed abortion of the first twin in conservative management]. / Zweizeitige Geburt nach spontanem Blasensprung und Spätabort des ersten Mehrlings bei konservativem Management.

INTRODUCTION: 1-2% of all twin pregnancies are complicated by premature contractions, leading to premature rupture of membranes before 26 weeks of pregnancy. In this situation, a decision is required to either actively induce premature delivery or to initiate expectant management. Maternal and fetal risks regarding perinatal mortality and morbidity and the benefits of pregnancy prolongation have to be weighted against each other. CASE REPORT: We present delayed deliveries of two I-Parae with dichorionic twin pregnancies, achieved by in vitro fertilisation. In both cases, spontaneous membrane rupture and miscarriage of the leading fetus occurred prior to 20 gestational weeks. As signs of infection were missing initially, we adopted a conservative, expectant management. In both cases, the pregnancies could be prolonged to more than 30 weeks' gestation. DISCUSSION: In the absence of additional risk factors, expectant, conservative management of multiple pregnancies after loss of one fetus can lead to pregnancy prolongation of 91 and 96 days, respectively. The gained gestational age of the remaining fetus and the healthy mother-child pairs are discussed under perinatal, economical and psychological aspects.

[Efficacy of vascular therapy in complex of treatment of purulent necrotic foot ulcers in patients with diabetes mellitus]. / Efektyvnist' sudynnoï terapiï v kompleksi likuvannia hniino-nekrotychnoho urazhennia stopy u khvorykh na tsukrovyi diabet.

The result of treatment of purulent-necrotic affection of foot (PNAF) in 151 patients with diabetes mellitus (DM) was estimated. The conduction of preoperative medicinal therapy is mandatory for the general status of patient stabilization only. After prescribing of heparin, no-spa, papaverin, rheopolyglucinum, solcoseryl, aspirin the foot tissues blood supply is changing nonvitally, the foot tissues blood supply while the alprostan intravenous infusion improves significantly. The alprostan prescription during performance of operative intervention on foot in patients with PNAF, caused by DM, and in the collateral blood flow decompensation of the leg and foot arteries is mandatory.

Volume sonography of the pelvic floor in nulliparous women and after elective cesarean section.

OBJECTIVE: To describe the sonographic appearance of the pelvic floor which has not been stressed by forces of labor or vaginal delivery in pregnant women and after childbirth. SUBJECTS AND METHODS: In a prospective observational study 14 nulliparous women during first trimester pregnancy and 26 primiparous women after elective cesarean were examined within the first week postpartum. The integrity of the internal anal sphincter expressed as the ratio between the anterior and the posterior internal anal sphincter muscle thickness (a/p-ratio), asymmetry of the levator ani muscle and the paraurethral fixation of the lateral vaginal edges at the arcus tendineus were assessed using volume sonography. RESULTS: The a/p-ratio in nulliparous women was significantly higher (p<0.01) than after elective cesarean section. Asymmetry of the levator ani muscle did not differ between both groups but was more frequently in the nulliparous patients with an odds-ratio of 1.16 (CI 0.74-1.82). In both groups of women the paraurethral fixation of the lateral vaginal edges were above the suburethral level of the vagina. CONCLUSIONS: This study gives sonographic features of the pelvic floor in nulliparous women and in primigravidae after elective cesarean section. Data from the post-cesarean group can serve as reference values for further studies evaluating pelvic floor damage after various modi of vaginal delivery.

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.

Efficacy and safety of intravenously administered iron sucrose with and without adjuvant recombinant human erythropoietin for the treatment of resistant iron-deficiency anemia during pregnancy.

OBJECTIVE: This study was undertaken to determine the efficacy and safety of intravenously administered iron sucrose with versus without adjuvant recombinant human erythropoietin in the treatment of gestational iron-deficiency anemia resistant to therapy with orally administered iron alone. STUDY DESIGN: Forty patients with gestational iron-deficiency anemia were randomly assigned to receive intravenously iron sucrose plus recombinant human erythropoietin or iron sucrose alone twice weekly. Target hemoglobin value was 11.0 g/dL. Efficacy measures were reticulocyte count, increase in hematocrit, and time to target hemoglobin level (treatment duration in weeks and need for continued therapy after 4 weeks). RESULTS: Both regimens were effective, but with adjuvant recombinant human erythropoietin the reticulocyte counts were higher from day 4 (P<.01), increases in hematocrit were greater from day 11 (P <.01), and the median duration of therapy was shorter (18 vs 25 days), with more patients reaching the target hemoglobin level by 4 weeks of treatment (n = 19 vs. n = 15). The groups did not differ with respect to maternal-fetal safety parameters. CONCLUSION: Adjuvant recombinant human erythropoietin safely enhanced the efficacy of iron sucrose in the treatment of gestational iron-deficiency anemia resistant to orally administered iron alone.

Reference values of fetal peak systolic blood flow velocity in the middle cerebral artery at 19-40 weeks of gestation.

OBJECTIVES: The objectives of this prospective study were (i) to establish new reference values of peak systolic blood flow velocity measurement in the fetal middle cerebral artery (MCA-PSV) following validated methodological guidelines and (ii) to develop a method to calculate Z-scores of MCA-PSV. PATIENTS AND METHODS: Cross-sectional data were obtained from 331 pregnant women between 19 and 40 weeks' gestation. Reference ranges for MCA-PSV were constructed and for each measurement linear regression models were fitted separately to the mean and standard deviations (SD) as a function of gestational age. An application to calculate Z-scores was developed. A comparison was made between the reference ranges produced in our study and those of a previous one. RESULTS: A new chart, table of centiles and regression equations of MCA-PSV are presented. Comparison of our reference ranges with ones produced in a previous study showed similar 5th centile values. However, the values for the 50th and 95th centiles between 19 and 28 gestational weeks were lower in our study. CONCLUSIONS: We have constructed reference ranges for MCA-PSV which, because they are derived from a larger number of examinations in the 15-20-week period and because the methodological flaws of the previously published study have been eliminated, we consider to be more accurate and therefore more useful for clinical practice.

Gustatory and olfactory function in the first trimester of pregnancy.

OBJECTIVE: To investigate gustatory and olfactory sensitivity in the first trimester of pregnancy using validated test kits. DESIGN: Prospective study. SETTING: Department of Obstetrics, University Hospital Zurich, Switzerland. POPULATION: Total 53 pregnant women and 59 controls in a known phase of the menstrual cycle. METHOD: Gustatory sensitivity was assessed by requiring subjects to discriminate between four basic-taste tablets ('sweet', 'salty', 'sour', and 'bitter'). Olfactory testing was performed using the 'Sniffin' sticks' kit. Subjects rated the intensity and hedonic tone of the four tastants and of 10 common odors. RESULTS: Pregnant women had significantly lower overall gustatory sensitivity scores. There were no differences in olfactory sensitivity. However, pregnant women rated the odors 'rum', 'cigarette' and 'coffee' as more aversive than did non-pregnant women. CONCLUSION: Our data do not support the hypothesis of a generalized increase in chemosensitivity in early pregnancy. In terms of adaptive changes of the olfactory system may act as a sentinel to potentially harmful chemicals. In contrast, the gustatory system appears to retreat to allow a greater intake of electrolytes and a more widely sourced diet.