Caso raro de embolia para o tronco da coronária esquerda, visto por ecocardiografia / Rare case of embolism to the left main coronary artery, seen by echocardiography

Pacientes com próteses valvares cardíacas podem apresentar complicações como trombose de prótese e endocardite infecciosa, elevando a morbimortalidade e frequentemente ocasionando a necessidade de reoperação. O ecocardiograma é o principal método utilizado no seguimento clínico e por vezes o diagnóstico do mecanismo de disfunção protética pode ser desafiador. RELATO DE CASO: Paciente de 54 anos, com antecedente de troca valvar mitral biológica em 2006, implante de marcapasso e fibrilação atrial permanente em anticoagulação com varfarina. Admitido no pronto-socorro em 2021 com febre e piora de classe funcional. Ao exame, apresentava-se em mau estado geral, confuso, taquidispnéico, com edema de membros inferiores e hipotensão arterial. Os exames laboratoriais evidenciaram hemograma com anemia, leucocitose com desvio à esquerda, marcadores inflamatórios elevados, INR fora da faixa terapêutica de anticoagulação (INR: 1,46). Eletrocardiograma em ritmo de marcapasso (FC 60 bpm). Ecocardiograma transtorácico com complementação esofágica mostrou aumento importante cavidades esquerdas, alteração segmentar (nova) grave em território de coronária esquerda, fração de ejeção reduzida em grau importante (FEVE= 14%, pelo método Simpson). Prótese mitral com folhetos espessados e mobilidade reduzida, área efetiva de fluxo= 1,2cm² (planimetria tridimensional), presença de múltiplas imagens ecogênicas em face ventricular com componente móvel, sugestivas de endocardite. Observou-se imagem ecogênica medindo 12 x 09 mm, relacionada ao seio coronariano esquerdo, estendendo-se para o interior do tronco da coronária esquerda (TCE), causando sua obstrução. Paciente evoluiu com piora clínica, choque refratário e óbito após 2 dias da admissão, não foi realizada autópsia para determinação diagnóstica da imagem ecogênica. DISCUSSÃO E CONCLUSÃO: O diagnóstico diferencial das massas embolizadas por ecocardiografia é desafiador, principalmente em casos cuja clínica sugere mais de uma possibilidade de fonte de embolia. O paciente descrito era portador de uma prótese cardíaca com alteração estrutural degenerativa suscetível tanto para quadro trombótico quanto para infeccioso (endocardite). Existem na literatura, relatos de diagnóstico de embolia séptica para a árvore coronária, a maioria deles, confirmado por cateterismo ou anatomia patológica (post mortem). Na revisão de literatura, não encontramos relatos de diagnóstico de embolia coronária feito por ecocardiografia, seja de trombose ou de vegetação, sendo, portanto, considerado um caso extremamente raro ou inclusive inédito.

The effect of subclinical endometritis on reproductive performance in postpartum Bos indicus multiparous beef cows.

The objective was to investigate the prevalence of subclinical endometritis (SE) in postpartum Bos indicus multiparous beef cows using different polymorphonuclear cells (PMN) threshold ratios, and to evaluate the impacts of SE on their reproductive performance. A total of 689 postpartum Nellore cows (45.2 ± 7.8 days postpartum) were submitted to an estrus synchronization protocol + timed-artificial insemination (TAI). Endometrial cytology samples were collected by cytobrush before the beginning of the protocol. Cows were considered positive for SE if: (PMN) ≥ 3% (PMN3), PMN ≥ 5% (PMN5) and PMN ≥ 7% (PMN7). Pregnancy diagnosis was performed at 30 and 100 d after TAI. The prevalence of cows categorized as positive for SE increased (P < 0.05) as the threshold was lowered (PMN7 = 3.9%; PMN5 = 5.5%; PMN3 = 9.1%). Positive SE cows had similar (P > 0.41) BCS, days postpartum, and expression of estrus at TAI compared with negative SE cows. Positive SE cows had decreased (P = 0.04) pregnancy rates compared to negative SE cows in the PMN5 threshold (26.3 ± 8.7% vs 44.5 ± 4.1%); however, no difference (P > 0.45) was observed between positive and negative SE cows in the PMN3 and PMN7 thresholds. Embryonic mortality between days 30 and 100 was not affected by SE (P > 0.16). In conclusion, the prevalence of SE varies based on the PMN threshold used, whereas SE at the beginning of the TAI protocol decreased the pregnancy rates in postpartum Bos indicus beef cows when the PMN5 was used.

What is the role of glycemic control in the development of preeclampsia among women with type 1 diabetes?

OBJECTIVE: To investigate the role of glycemic control in development of preeclampsia (PE) in women with type 1 diabetes mellitus (T1DM). METHODS: An observational case-control study comparing 244 women with type 1 diabetes and 488 controls was conducted. Among women with T1DM HbA1c, average daily glucose values, fasting, preprandial, 1-hour and 2-hour postprandial glucose levels, and daily 3 meals postprandial glucose areas were evaluated. Uterine artery pulsatility indices (PI) at 16, 20, 24 weeks' gestation were obtained. Data analysis included rates of PE in both groups, and association between glycemic control, uterine artery PI and development of PE among women with T1DM. RESULTS: PE developed in 13.1% of diabetic women and in 3.5% of women in the control group (odds ratio 4.2; 95% CI 2.2-8.1). In multivariate logistic regression analysis, HbA1c in the 1st trimester, mean daily glucose level in the 1st and 2nd trimester, daily 3 meal postprandial glucose area in the 1st and 2nd trimester, and the uterine arteries PI at 24 weeks' gestation were found to be associated with development of PE. The uterine arteries PI showed a significant positive correlation with the 3 meal postprandial glucose area at 16, 20, 24 weeks. CONCLUSION: In women with T1DM, poor glycemic control early in pregnancy is associated with an increased risk of subsequent PE. An association between poor placentation, as indicated by the increased PI of uterine arteries, and a maternal metabolic factor, that is the 3 meal post-prandial glucose area, has been shown, supporting the increased rate of PE among women with T1DM.

Analysis of the main risk factors for gestational diabetes diagnosed with International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria in multiple pregnancies.

INTRODUCTION: The aim is to investigate the proportion of multiple pregnancies with gestational diabetes mellitus (GDM) diagnosed using the International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria and to identify the impact of age, body mass index (BMI), and mode of conception on incidence of GDM. MATERIALS AND METHODS: This is a single center, retrospective cohort study on 656 multiple pregnancies screened for GDM with 75-g, 2-h oral glucose tolerance test at 24-28 weeks of gestation, between January 2010 and January 2016. The diagnosis of gestational diabetes mellitus (GDM) was reached through the IADPSG. RESULTS: The incidence of GDM in our population was 15.1%. When patients who conceived through heterologous assisted reproduction technology were compared with those who conceived spontaneously, there was a significant difference for GDM (31.1 vs 13.6%, p < 0.001, OR 2.86). A similar finding was also observed comparing egg donation IVF/ICSI patients with homologous IVF/ICSI patients (31.1 vs 14.8%, p = 0.006, OR 2.59). Incidence of GDM was significantly higher in obese than in non-obese patients (42.5 vs 14.8%, p < 0.001, OR 4.88) and in women over 35 compared to younger patients (18.4 vs 11.1%, p = 0.01, OR 1.81). Logistic regression comparing the diabetes onset with conception mode gave a p = 0.07. The calculation of the Chi-square and odds ratio for single mode of conception showed that homologous vs conceived spontaneously p = 0.90, OR 0.97, heterologous vs homologous p = 0.01 with OR 2.46, and heterologous vs conceived spontaneously p = 0.01 with OR 2.39. Logistic regression showed that age and BMI are risk factors for developing GDM, respectively, p = 0.03 with OR 1.4 and p < 0.01 and OR 1.09. DISCUSSION: The contribution our study can make is improved counseling about GDM risks for couples with multiple pregnancies. Our data support the role of age, BMI, and mode of conception as risk factors for GDM in multiple pregnancies.

Management of coronal discolouration following a regenerative endodontic procedure in a maxillary incisor.

Pulpal necrosis and infection in an immature anterior tooth subsequent to traumatic injury is a challenging situation. Regenerative endodontics, resulting in continued development of the tooth, provides a biological response to this clinical challenge. Regenerative endodontic procedures require disinfection of the infected root canal and sealing of the pulp canal space. Mineral trioxide aggregate (MTA) provides a good seal, is biocompatible and allows the formation of a hard tissue to occur within the root canal. MTA, however, can lead to significant staining of the crown of the tooth that is difficult to mask. This case report describes the management of discolouration in an 11 year old girl subsequent to a regenerative endodontic procedure in an immature traumatized maxillary central incisor.

Staphylococcal enterotoxin A regulates bone marrow granulocyte trafficking during pulmonary inflammatory disease in mice.

Pulmonary neutrophil infiltration produced by Staphylococcal enterotoxin A (SEA) airway exposure is accompanied by marked granulocyte accumulation in bone marrow (BM). Therefore, the aim of this study was to investigate the mechanisms of BM cell accumulation, and trafficking to circulating blood and lung tissue after SEA airway exposure. Male BALB/C mice were intranasally exposed to SEA (1µg), and at 4, 12 and 24h thereafter, BM, circulating blood, bronchoalveolar lavage (BAL) fluid and lung tissue were collected. Adhesion of BM granulocytes and flow cytometry for MAC-1, LFA1-α and VLA-4 and cytokine and/or chemokine levels were assayed after SEA-airway exposure. Prior exposure to SEA promoted a marked PMN influx to BAL and lung tissue, which was accompanied by increased counts of immature and/or mature neutrophils and eosinophils in BM, along with blood neutrophilia. Airway exposure to SEA enhanced BM neutrophil MAC-1 expression, and adhesion to VCAM-1 and/or ICAM-1-coated plates. Elevated levels of GM-CSF, G-CSF, INF-γ, TNF-α, KC/CXCL-1 and SDF-1α were detected in BM after SEA exposure. SEA exposure increased production of eosinopoietic cytokines (eotaxin and IL-5) and BM eosinophil VLA-4 expression, but it failed to affect eosinophil adhesion to VCAM-1 and ICAM-1. In conclusion, BM neutrophil accumulation after SEA exposure takes place by integrated action of cytokines and/or chemokines, enhancing the adhesive responses of BM neutrophils and its trafficking to lung tissues, leading to acute lung injury. BM eosinophil accumulation in SEA-induced acute lung injury may occur via increased eosinopoietic cytokines and VLA-4 expression.

Glucose Fluctuations during Gestation: An Additional Tool for Monitoring Pregnancy Complicated by Diabetes.

Continuous glucose monitoring (CGM) gives a unique insight into magnitude and duration of daily glucose fluctuations. Limited data are available on glucose variability (GV) in pregnancy. We aimed to assess GV in healthy pregnant women and cases of type 1 diabetes mellitus or gestational diabetes (GDM) and its possible association with HbA1c. CGM was performed in 50 pregnant women (20 type 1, 20 GDM, and 10 healthy controls) in all three trimesters of pregnancy. We calculated mean amplitude of glycemic excursions (MAGE), standard deviation (SD), interquartile range (IQR), and continuous overlapping net glycemic action (CONGA), as parameters of GV. The high blood glycemic index (HBGI) and low blood glycemic index (LBGI) were also measured as indicators of hyperhypoglycemic risk. Women with type 1 diabetes showed higher GV, with a 2-fold higher risk of hyperglycemic spikes during the day, than healthy pregnant women or GDM ones. GDM women had only slightly higher GV parameters than healthy controls. HbA1c did not correlate with GV indicators in type 1 diabetes or GDM pregnancies. We provided new evidence of the importance of certain GV indicators in pregnant women with GDM or type 1 diabetes and recommended the use of CGM specifically in these populations.

Stillbirth and fetal growth restriction.

OBJECTIVE: To confirm the role of fetal growth restriction (FGR) as a cause of stillbirth, and to compare diagnostic accuracy of customized fetal growth and population-based standards in identifying FGR within a pathological population of early and late stillbirths. METHODS: Retrospective study on a cohort of 189 stillbirths occurred in single pregnancy between January 2006 and September 2011. Unexplained stillbirths, defined by Aberdeen-Wigglesworth and ReCoDe classifications, were evaluated on the basis of fetal birthweight with both Tuscany population and Gardosi customized standards. Unexplained stillbirths have been classified as early or late depending on the gestational age of occurrence. RESULTS: Aberdeen-Wigglesworth classification, applied to the 189 cases of stillbirth, left 94 unexplained cases (49.7%), whereas the ReCoDe classification left only 40 (21%). By applying population standards to the 94 unexplained stillbirths we have identified 31 FGRs (33% of sample), while customized standards identified 54 FGRs (57%). Customised standards identified a larger number of FGRs with respect to population standards during the third trimester (i.e. 51% vs. 25% respectively) than in the second trimester (73% vs. 54% respectively) (p = 0.05). CONCLUSIONS: Customized standards have a higher diagnostic accuracy in identifying FGRs especially during the third trimester.

Amoxicillin prophylaxis in oral surgery.

INTRODUCTION: Postoperative infection is the most common postsurgical oral complication but no double-blind, randomized, placebo-controlled trial has been made yet to assess amoxicillin prophylaxis for oral surgery. The aim of this pilot study was to assess the effectiveness of prophylactic amoxicillin 3g per os versus placebo in the prevention of postoperative oral infections. METHODS AND MATERIALS: A 5-year, multicentric, randomized, double-blind clinical trial was made on healthy patients undergoing complex oral surgery. Final analysis was by intention to treat. RESULTS: The 286 patients were randomly assigned to the amoxicillin or placebo group. After a mean follow-up of two weeks, 11 patients in the control group and three patients in the amoxicillin prophylaxis group developed a postoperative infection (P=0.001 in unilateral test). The hazard ratio was 0.27 [95% CI: 0.07-0.94]. CONCLUSION: Amoxicillin prophylaxis seems to be effective in preventing postoperative infection in complex oral surgery, especially when mandibular third molars and multiple avulsions are involved.

[Ablation profiles in refractive surgery. Part 1: in search of excellence]. / Les profils de photoablation cornéenne en chirurgie réfractive. Partie 1 : la quête de l'excellence.

PURPOSE: To provide an overview of the clinical results of various ablation profiles and discuss their technical characteristics and limitations. MATERIALS AND METHODS: Literature review. RESULTS: With the emergence of wavefront technology, new photoablation profiles have been developed, allowing for customization of refractive treatments and reduction of nocturnal visual symptoms, which adversely affect the reputation of refractive surgery. Over the past decade, several comparative studies have been published in the literature aiming to demonstrate either the superiority of wavefront-guided correction over conventional, or one laser platform over another. However, has an ideal treatment algorithm really emerged from these studies? Does one ablation profile clearly demonstrate superiority over another, in terms of visual performance? CONCLUSION: Despite technological advances as well as improved visual results for custom versus conventional photoablation, the promise of excellence in visual performance has not been achieved with these various technologies. The concept of an individualized eye model has emerged recently, based on an optical ray tracing algorithm, and could theoretically provide an ideal ablation profile, thus fulfilling the promise of "supernormal vision".

OS086. Methylation status of the HOXA13 promoter region in placental tissue of pregnancies complicated by early onset severe preeclampsia.

INTRODUCTION: Compromised placental function and morphology found in early onset preeclampsia as well as a modified phenotype of the fetus may derive from a deviation in the normal gene expression pattern. Previous studies demonstrated by experimental animal models, that the gene HOXA13 plays an essential role in the arrangement of the placental vascular net, identifying direct and indirect target functions this gene has on the endothelial component. Research in model systems and now expanding to human studies has suggested that the causes and consequences of a variety of pregnancy-related pathologies are connected to epigenetic regulation. OBJECTIVES: To evaluate the methylation status of the promoter region of HOXA13 within placental tissue and its association with specific clinical signs of severe early onset preeclampsia. METHODS: A prospective case - control study was performed to evaluate the methylation status of the promoter region of HOXA13 by pyrosequencing analysis within placental tissue and its association with specific clinical signs of severe early onset preeclampsia (EOSP). RESULTS: The group of preeclamptic patients reached a mean methylation degree of 27.06% (±8.94) and 30.56% (±8.08) on two CpG islands of HOXA13 5' promoter respectively. Conversely in the group of physiologic controls the mean degree of methylation resulted 15.12%(±3.64) (p<0.0016) and 18.25% (±3.45) (p<0.0005). CONCLUSION: This study firstly demonstrated that an hypermethylation of placental HOXA13 exists in preeclamptic placental tissues and concentrates only on the gene promoter. Additionally, the existence of a correspondence between themethylation process of the gene promoter HOXA 13 and the clinical manifestation of severe early onset preeclampsia supports the original hypothesis that this process may be at the base of the preeclamptic pathogenesis.

PP109. Risk of preeclampsia in homologous and oocyte donation IVF pregnancies.

INTRODUCTION: Women who conceived by donor oocyte in vitro fertilization (IVF) are at high risk for placenta-related complications, because of advanced maternal age, nulliparity and maybe for an altered immune response. OBJECTIVES: The aim of this case-control study is to compare the incidence and the characteristics of preeclampsia in women who conceived by oocyte donor or by homologous IVF. METHODS: Data were collected from 65 consecutive women who conceived through oocyte donor IVF and 71 consecutive pregnancies from homologous IVF in women older than 35years (control group), who attended our institution between 2009 and 2011. Data are expressed as percentage, average and standard deviation (SD). Statistical analysis was performed by chi-square test for unpaired data and the results were considered significant with p<0.05. RESULTS: Thirteen women from the donor oocyte group were excluded because of first trimester miscarriage, ectopic pregnancy and lack of data. After the exclusion, 52 pregnancies from oocyte donation were compared to the control group. Baseline characteristics, such as maternal age, BMI, parity and prevalence of twin pregnancies were similar in the two groups. Preexisting hypertension was present only in the oocyte donor IVF group (n=6 cases). The risk of preeclampsia was significantly related to oocyte donor IVF (27% vs 5.6%, p=0.0024 OR=6.17), even when only singleton pregnancies were considered (16.7 vs 1.9%; p=0.02, OR=9). When women with preexisting hypertension were excluded, the incidence of severe preeclampsia remained significant (p=0.02). This result was not confirmed when both preexisting hypertension and twin pregnancies were excluded (p=0.09), even if the percentage of cases was higher in the oocyte donor IVF group (10.7% vs 1.85%). Three cases of life threatening severe preeclampsia occurred before the 24th week, two of which required interruption of pregnancy; one case was complicated by eclampsia. The two groups did not show significant differences in terms of prevalence of IUGR, both in multiple and singleton pregnancies, even if percentage values were higher in the donor IVF group (multiple: 21.2% vs 11.3%, p=0.21/ singleton 10% vs 5.6%, p=0.48). CONCLUSION: IVF with oocyte donation stands as an independent risk factor for preeclampsia. The risk of developing a severe and early preeclampsia may be increased when chronic hypertension occurs.

PP120. Hydatidiform mole as a cause of eclampsia in the first trimester: A case report.

INTRODUCTION: The occurrence of preeclampsia before the 20th week of gestation is rare and it has been associated with hydatidiform molar pregnancy. OBJECTIVES: We describe a case of first trimester eclampsia which occurred in a patient with hydatidiform mole. METHODS: Case report. RESULTS: A 16-year-old woman came to emergency service for abdominal pain and vaginal bleeding. She had been suffering of vomiting after meals and complaining for abdominal mass for 2months, without consulting her physician. The last reported period was 1month before; the patient told her periods were regular and the only disease she reported was chronic HBV hepatitis. Vital parameters were all normal. Urine pregnancy test resulted always negative. The gynecological exam reported an increased uterus and a little bleeding, so serum bhCG was performed because of the exam findings and resulted 110,5317UI/L. The transvaginal ultrasound showed images consistent with gestational trophoblastic disease. Computed tomography (CT) scan revealed the presence of an uterine mass and three lung nodules, reported as possibly metastatic. A few days later, the patient underwent dilation and curettage (D&C). Second grade hydatiform mole was diagnosed by histology. After D&C, the serum bhCG was 202,511UI/L. The day after, the patient presented bilateral acute blindness, followed by incoming general seizures, concurrent hypertension and tachycardia. Intravenous diazepam, levetiracetam and mannitol controlled the seizures, but the conscious state of the patient remained critical. Temperature reached 40°C, with concurrent leukocytosis. Then, a lumbar puncture was performed but it resulted negative for inflammatory/infective processes. A head CT was performed the same day and showed a posterior reversible encephalopathy syndrome (PRES). Intravenous methylprednisolone was started. Long term therapy with methylprednisolone and levetiracetam was effective and the patient's status improved and stabilized. A subsequent chemotherapy with EMA/CO regimen (etoposide, methotrexate, actinomycin D, cyclophosphamide, vincristine/oncovine) was performed for six cycles, until serum bhCG resulted negative and the abdomen/pelvis ultrasound, head NMR and chest X-ray resulted normal. CONCLUSION: Preeclampsia and eclampsia are regarded as common causes of PRES, which is considered to be the result of vasogenic brain edema. Clinical and imaging findings are usually reversible. Early diagnosis and elimination of possible causes are important in order to avoid permanent visual or brain injury. Imaging (especially MRI) should be carried out in eclamptic patients with visual disturbance in order to exclude other causes of blindness. Molar pregnancy is a rare but important cause of eclampsia, and it has always to be considered in case of early manifestations.

Staphylococcus aureus brainstem abscess in a Brazilian Amazon man. Case report.

The brainstem is an uncommon site for a brain abscess. It accounts for less than 4% of all posterior cranial fossa abscesses, and less than 1% of all intracranial abscesses. The pons is the most common site for these abscesses. The aim of the present report was to describe the case of a Brazilian Amazon man with a brainstem abscess (BSA) managed with combined surgical drainage and systemic antibiotic therapy. This case reinforces the importance of an early suspicion of BSA in patients with unexplained fever and neurologic deficits, especially sixth and seventh cranial nerve lesions, to minimize permanent damage.

[Bacteremia of oral origin]. / Bactériémies d'origine buccale.

Transient bacteremia from oral cavity related to oral anaerobic bacteria may occur as a result of dental healthcare procedures but also as a result of daily gestures involving the gums (chewing and oral hygiene). The risk of presenting a transient bacteremia is related to oral cavity bacterial load and to the severity of inflammation in the oral cavity. Although bacteremia is transient, in patients with immunodeficiency or comorbidity, this bacteremia may cause extra-oral infections. The bacteremia rate and the identified bacteria vary from one study to the next, depending on the method used to isolate and identify bacteria. Nevertheless, the risk for bacteremia is determined by the infectious and inflammatory conditions of each patient.

Prepregnancy BMI influences maternal and fetal outcomes in women with isolated gestational hyperglycaemia: a multicentre study.

AIM: This multicentre study analyzed the maternal and fetal outcomes of women who had one elevated 3-h oral glucose tolerance test (isolated gestational hyperglycaemia [IGH]). METHODS: From 1999 to 2003, data were collected for 606 IGH women from 31 Italian obstetric or diabetic centres, including time and mode of delivery, gestational hypertension, preeclampsia, eclampsia, congenital malformations, and neonatal mortality and morbidity, to compare them with the general pregnant Italian population. A prognostic model for the outcome of pregnancy was constructed, and the concurrence of certain specified conditions was considered a positive outcome, whereas pregnancies that failed to meet one or more of the stated conditions were classified as "complicated". RESULTS: Macrosomia was significantly more frequent in women with IGH than in the normal pregnant population (10.7 vs 7.4%, respectively; P=0.003). Stillbirth and neonatal mortality rates did not differ from those in normal pregnancies, while a slight rise in the frequency of major malformations was not statistically significant (1.48 vs 0.89%, respectively; P<0.11). Multivariate logistic analyses confirmed that the prepregnancy body mass index (BMI) was an independent predictor of a complicated pregnancy. As for fetal growth, multivariate logistic analyses according to BMI showed that being overweight or obese were strong predictors of macrosomia. CONCLUSION: These findings in a large cohort of Italian women with IGH confirm the detrimental effect of even minimally altered glucose tolerance on fetal outcome. Also, prepregnancy obesity plays an important role in raising the risk of adverse perinatal outcomes in such patients.

Severe fibrotic changes and altered expression of angiogenic factors in maternal scleroderma: placental findings.

OBJECTIVE: Pregnant women with systemic sclerosis (SSc; scleroderma) have an increased risk of premature delivery and small full-term infants. During placental development, angiogenesis and vascular remodelling are essential for a successful pregnancy outcome. An analysis was made of the pathological changes and expression of angiogenic factors in SSc placentas. METHODS: Placenta biopsies were obtained from three patients with SSc and four healthy uncomplicated pregnancies after delivery at 34-38 weeks of gestation. The sections were stained with Masson's trichrome and phosphotungstic-acid-haematoxylin and immunostained for connective tissue growth factor (CTGF), alpha-smooth muscle actin (alpha-SMA), vascular endothelial growth factor (VEGF), placenta growth factor (PlGF) and receptors VEGFR-1 and VEGFR-2. RESULTS: The pathological findings were signs of decidual vasculopathy, increased syncytiotrophoblast knotting, placental infarcts and villous hypoplasia. Severe and diffuse perivascular and stromal fibrosis of decidua and chorionic villi, and extensive deposition of fibrinoid material around decidual vessels and in intervillous spaces were observed. Strong CTGF expression in the vessel wall, decidual cells and fibroblasts and alpha-SMA+ myofibroblasts were found. VEGF and VEGFR-2 expression was stronger in SSc than in healthy placentas, while VEGFR-1 expression was similar to controls. PlGF immunopositivity was weaker in SSc. CONCLUSION: In SSc placentas, severe fibrosis and abnormal vascular remodelling were detected. This may result in reduced blood flow leading to deep sufferance of maternal placenta and possible premature delivery.