Acute Abdomen in the 17th Week of Twin Pregnancy due to Ovarian Torsion - A Late Complication of IVF.

Background: A 32-year-old woman with tubal factor infertility due to bilateral laparoscopic salpingectomy conceived twins with in vitro fertilization (IVF). She developed moderate ovarian hyperstimulation syndrome which was treated with anticoagulant therapy. The subsequent course of the twin pregnancy was normal until the 17th week of gestation when she presented to hospital because of a sharp pain in the right lower abdomen which ceased after admission. Case: Except for a single incident of vomiting, patient had no other subjective symptoms. The clinical examination showed tenderness of the lower right abdominal segment on palpation. The surgeon and the urologist found no signs of an acute surgical or urologic condition, and laboratory findings were within normal reference ranges for pregnant women. Two days after admission the pain reappeared; it was now much stronger and colic-like. The pain was initially located supraumbilically but subsequently spread diffusely across the lower abdomen. Abdominal guarding was present and laboratory findings showed an increase in inflammatory parameters. An enlarged and edematous right ovary was found on transvaginal ultrasound. Conclusion: Exploratory laparotomy via a vertical midline abdominal transection revealed a torqued necrotic right ovary with elements of inflammation and inflammatory adhesions involving the entire pelvis. The patient underwent right-sided ovariectomy and adhesiolysis. Recovered was normal and the patient was delivered of healthy twins in the 37th week of gestation.

Antenatal detection of mosaic trisomy 9 by ultrasound: a case report and literature review.

This paper presents a fetus with mosaic trisomy 9 diagnosed by chorionic villus sampling and confirmed by cordocentesis, and compares this case with published cases in order better to define the ultrasound markers confined to trisomy 9 syndrome. Detailed fetal ultrasound examination was carried out, revealing shortened femur, placental cysts and oligohydramnios. All published trisomy 9 cases with abnormal ultrasound findings were extracted from the MEDLINE database in the period from 1973 to 2002. We found 12 non-mosaic and 13 mosaic cases, including our case. The most frequent ultrasound abnormalities included characteristic cardiac, skeletal, craniofacial and central nervous system malformations. Intrauterine growth restriction and single umbilical artery were prevalent non-specific findings in both non-mosaic and mosaic groups. Parental chromosomal variations, as in our case, were not uncommon findings. When a fetus shows structural anomalies suggesting the presence of trisomy 9, karyotyping should be performed on both chorionic villi or amniocytes and fetal blood lymphocytes to enable a correct diagnosis to be made.

[Study of intervillous blood circulation using color and pulsed doppler ultrasound]. / Istrazivanje interviloznog optoka krvi s pomocu obojenog i pulzirajuceg Doplerskog ultrazvuka.

Studies of the formation and hemodynamics of intervillous circulation aroused great scientific interest in the past few years. The reason for this is development of the technology of color Doppler ultrasound, which can non-invasively in vivo follow-up changes in intervillous circulation during all three trimesters of gestation. The results of Doppler ultrasound measurements have been compared to histological and embryological findings. Different experimental findings and theories induced intensive scientific discussions about the timing of the formation of intervillous circulation, as well as about possible significance of hemodynamic changes in physiological and pathological processes in early and late gestation. In this review article we tried to acquaint the broader professional readership with this interesting subject, and to present our results and viewpoints after several years of the study of intervillous circulation with color Doppler.

[Huge retrovesical tumor as an incidental finding: desmoid-type fibromatosis: a case report]. / Monströse retrovesikale Raumforderung als Zufallsbefund : Desmoidfibromatose: ein Fallbericht.

We report the case of a 57-year-old patient with a huge, retrovesical, aggressive desmoid fibromatosis detected incidentally during preoperative staging for radical prostatectomy. The tumor was locally invasive consisting of monoclonal and fibroblastic proliferations. The etiology of such tumors is not well known but they are mostly sporadic and aggressive fibromatosis is sometimes associated with familial adenomatous polyposis (FAP) or Gardner's syndrome. Such desmoid tumors are slow growing and locally invasive but lack metastatic potential. Complete resection with wide margins is the therapy of choice and the tendency to recur is high. Radiotherapy following surgery is controversial. We discuss the pathogenesis, clinical manifestations and therapy of such rare tumors.

[Radical prostatectomy - pro laparoscopic]. / Radikale Prostatektomie - pro laparoskopisch.

Recent publications have failed to demonstrate significant differences in perioperative oncological and functional outcomes between laparoscopic radical prostatectomy (LRPE) and R-LRPE. Reports suggesting better functional results, in particular better potency rates for R-LRPE, are rare. However, to date no large prospective, randomized, multicenter studies have compared the two methods. With an experienced operator both methods produce comparably good results. The monopoly of the intuitive system with extremely high cost of purchase and maintenance are the major disadvantages of R-LRPE.

Three-dimensional sonography in prenatal diagnosis: a luxury or a necessity?

Three-dimensional sonography revolutionized ultrasound imaging with its capacity to depict an unlimited number of planes in which the object of interest can be displayed. The addition of numerous modalities of image rendering promotes three-dimensional sonography to the top of the spectrum of diagnostic imaging in obstetrics and gynecology. The aim of this article is to present our experience in 3-D sonography during the second and third trimester of pregnancy and to give a comparative review of literature. 247 patients in gestational age ranging from 12 to 40 weeks of gestation were examined over a three year period. The majority of patients entered the study because fetal anomaly was suspected at two-dimensional sonography. Some patients were sent on to three-dimensional sonography because it was not possible to depict clearly normal fetal anatomy by two dimensional sonography. Out of 170 fetal anomalies three-dimensional sonographic analysis failed in only three cases. In all three anomaly was accompanied with severe oligohydramnios. Main advantages of three-dimensional ultrasound in perinatal medicine and antenatal diagnosis include scanning in the coronal plane, improved assessment of complex anatomic structures, surface analysis of minor defects, volumetric measuring of organs, "plastic" transparent imaging of fetal skeleton, spatial presentation of blood flow arborization and, finally, storage of scanned volumes and images. It is our decided opinion that three-dimensional sonography has gained a valuable place in prenatal diagnosis, becoming a necessity for every modern perinatal unit.

Gamma-vinyl GABA: comparison of neurochemical and anticonvulsant effects in mice.

Biochemical and pharmacological effects of gamma-vinyl GABA (Vigabatrin, GVG), and irreversible enzyme-activated inhibitor of 4-aminobutyrate: 2-oxoglutarate aminotransferase (EC 2.6.1.19; GABA-T), were measured in mice. This anticonvulsant produced a time- and dose-dependent elevation of the GABA, phenylalanine and lysine contents of cortical tissue and simultaneously decreased glutamate, aspartate and alanine levels. In addition, GVG caused a biphasic change in glutamine concentrations (a decline 1-4 hours after administration, followed 20 hours later by an increase). Moreover, we found a new, as yet unidentified amino acid in the brain eluting with the same retention time as alpha-aminoadipic acid from an HPLC cation-exchange column. The level of this novel chemical entity was greatly increased by GVG 20 hours after injection of the drug. At all tested intervals between 1 and 60 hours after injection, GVG was ineffective against maximal electroshock. The GABA-T inhibitor dose-dependently protected mice against isoniazid-induced seizures, simultaneously causing an increase in brain GABA concentrations. However, this apparent correlation applied only until 4 hours after treatment. To better define the anticonvulsant profile of GVG, groups of mice were treated, 1, 2, 4, and 24 hours prior to challenge with convulsant doses of strychnine, pentetrazole (PTZ), and picrotoxin, and brain amino acid levels, including brain concentrations of GVG, were measured. In all instances, the time dependency of the anticonvulsant effects of GVG and of increases in brain GABA levels differed. Amino acid concentrations in animals treated only with GVG were similar to those in animals given GVG and a chemical convulsant. GVG showed no selectivity for seizures produced by impairment of GABA-ergic neurotransmission. Although GVG is an effective GABA-T inhibitor, it apparently affects several other pyridoxal-phosphate-dependent cerebral enzymes and/or interacts with other neurotransmitter systems as well.

Blockade of GABAB receptors accelerates amygdala kindling development.

The aim of this study was to investigate the putative role of GABAB receptors in the development of amygdala kindling in rats. The effects of the GABAB blocker CGP 35348 and the GABAB agonist baclofen on the progressive development of behavioural seizure symptoms (stages 1-5 classified by Racine) and duration of after-discharges (AD) were studied. CGP 35348 at a dose of 300 mg/kg i.p., which blocks central GABAB receptors, moderately but consistently accelerated the development of behavioural seizure symptoms. CGP 35348 had no marked effect on the duration of ADs corresponding to the different seizure stages. L-baclofen (6 mg/kg i.p.) had a dual effect on kindling development. It retarded the development of the behavioural symptoms, but increased the duration of AD. In conclusion, the results suggest that synaptically-released GABA activated GABAB receptors and thereby exerted a depressant effect on kindling development.

Intervillous circulation in all three trimesters of normal pregnancy assessed by color Doppler.

Our cross-sectional study included 115 healthy pregnant women in gestational age between 7 and 24 weeks. The aim of the study was to compare resistance (RI) and pulsatility (PI) indices, peak systolic velocity (PSV), end-diastolic velocity, and temporal averaged maximum velocity (TAMV) of the spiral arteries and vessels within the intervillous space in all three trimesters of pregnancy. The impedance to blood flow within the intervillous space significantly decreased towards the mid-pregnancy (p < 0.01) and then remained stable. Blood flow velocities within the intervillous space expressed by PSV, EDV and TAMV increased significantly (p < 0.01) towards the mid-pregnancy. After reaching the plateau between 16 and 22 weeks of gestation, these parameters remained almost constant until the 36th gestational week. Near the term low-significant decrease of blood flow velocities was noted: for PSV and TAMV p < 0.07, and for EDV p < 0.05. A significant increase in continuous intervillous blood flow velocity was noted from the 11th week onward (28 +/- 12 vs. 36 +/- 12) until the 36th week of gestation (36 +/- 12 cm/s). The first report of the haemodynamic changes within the intervillous space during pregnancy may have implication in better understanding of the metabolical interchange between maternal and fetal side.

Conflicting data on intervillous circulation in early pregnancy.

According to classic embryological textbooks intervillous circulation is established early in the first trimester. This process starts with trophoblastic invasion of the decidua in which proteolytic enzymes facilitate the penetration and erosion of the adjacent maternal capillaries with formation of the lacunae. After the lacunar or previllous stage trophoblast invades deeper portions of endometrium with belonging spiral arteries. This gradual process finishes with direct opening of the spiral arteries in the intervillous space under the fully developed placenta. This classic concept of establishment of the intervillous circulation was challenged in 1987 and 1988 by the experiments of HUSTIN and SHAAPS. The authors believed that blood flow in the intervillous space is absent in incompletely development before 12 weeks of gestation. After the introduction of the new generation of far more sensitive color Doppler devices in the last few years, our group and several others reported a positive finding of intervillous circulation during the first trimester of pregnancy.

Intervillous blood flow in patients with missed abortion.

AIM: Analysis of the color Doppler features of intervillous flow in cases of missed abortion, and their comparison with the findings in normal pregnancy. METHODS: Transvaginal color and pulsed Doppler was used in the analysis of 38 patients with missed abortion and 40 patients with normal pregnancy. The gestational age ranged from 6 to 11 weeks. Repeated analysis of variance was used to compare the groups. RESULTS: Two types of Doppler signals were detected in the intervillous space: pulsatile and continuous. Impedance in the intervillous space of both groups did not change significantly with the gestational age. For the group with missed abortion, the mean resistance index (RI) was 0.37 +/- 0.03 and pulsatility index (PI) 0.75 +/- 0.07. For the control group, the mean RI was 0.36 +/- 0.02 and PI 0. 72 +/- 0.04. The differences in RI and PI for all gestational age groups and between the two patient groups were not statistically significant. With advancing gestation, continuous, venous-like signal became stronger and randomly dispersed throughout the placenta. Peak flow velocity values obtained from both groups did not change significantly with gestational age, nor between the two groups. Conclusion. The new generation of sensitive Doppler units can detect the intervillous flow as a continuous progressive process at 6-11 weeks of gestation. The vascular resistance in the intervillous space does not change in cases of missed abortion.

The study of morphology and circulation of early embryo by three-dimensional ultrasound and power Doppler.

Three-dimensional (3-D) ultrasound plays an important role in obstetrics predominantly for assessing fetal anatomy. Presenting volume data in a standard anatomic orientation assists both ultrasonographers and pregnant patients to recognize anatomy more readily. Three-dimensional ultrasound is advantageous for the study of normal embryonic and/or fetal development, as well as providing information for families at risk for specific congenital anomalies by confirming normality. This method offers advantages in assessing the embryo in the first trimester as it is able to obtain multiplanar images through endovaginal volume acquisition. Rotation of the embryo and close scrutiny of the volume allow the systematic review of anatomic structures such as cord insertion, limb buds, cerebral cavities, stomach and bladder. Using this modality one can easily obtain the volumes of the gestational sac and yolk sac and can evaluate their relationship to prediction of pregnancy outcome. Three-dimensional power Doppler sonography has the potential to study process of placentation and evaluate the development of the embryonic and fetal cardiovascular systems. Three-dimensional ultrasound imaging in vivo compliments pathologic and histologic evaluation of the developing embryo, giving rise to a new term: 3-D sonoembryology. Rapid technological development will allow real-time 3-D ultrasound to provide improved and expanded patient care on the one side, and increased knowledge of developmental anatomy on the another.

The effectiveness of non-surgical management of early interstitial pregnancy: a report of ten cases and review of the literature.

OBJECTIVE: To assess the effectiveness of non-surgical management of interstitial pregnancy. DESIGN: A prospective interventional study. SUBJECTS: Eleven women with the ultrasound diagnosis of interstitial ectopic pregnancy. METHODS: Women with suspected early pregnancy complications were examined by transvaginal ultrasound. Those with the diagnosis of interstitial pregnancy were offered non-surgical treatment with methotrexate, which was administered systemically or by local injection. Follow-up with regular measurements of beta-human chorionic gonadotropin and ultrasound scans continued until the pregnancy had resolved completely. RESULTS: Ten women were managed non-surgically, and one woman opted for surgery. Five women received systemic and five local methotrexate. Local therapy was successful in all five cases (100%), whereas four out of five (80%) women receiving systemic methotrexate were cured. Significant side-effects were noted in two women following systemic therapy. In comparison, there were no side-effects in the group of women who received local therapy. There were no significant differences between the two treatment groups in the length of time taken for the pregnancy to resolve. CONCLUSIONS: Non-surgical treatment of interstitial pregnancy with methotrexate appears to be safe and effective. Local administration appears to be more successful and better tolerated by patients and may be used as the first-line therapy.

Doppler information pertaining to the intrapartum period.

The aim of the study was to evaluate the use of color-Doppler velocimetry during the labor. 325 intrapartal measurements of the umbilical artery, fetal aorta, middle cerebral artery and arcuate arteries were performed in a group of 105 patients. The resistance index (RI) and pulsatility index (PI) were measured. During the active labor the RI and PI of the umbilical artery remained unchanged. The impedance in arcuate arteries have increased (p < 0.05). The RI and PI of the middle cerebral artery showed non significantly increased mean values when compared with the corresponding values during pregnancy. But, a short term, transitory decreased impedance is registered during the decrement slope of contraction. Since fetal outcome was normal in all newborns, these changes are considered as physiologic.

Assessment of early placental development in the cynomolgus monkey (Macaca fascicularis) using colour and pulsed wave Doppler sonography.

Colour flow mapping and pulsed wave Doppler were used to assess the process of placental growth and development in the cynomolgus monkey from 32 to 71 days gestational age. Fetal and maternal vessels were reliably visualised and insonated. Accurate longitudinal non-invasive assessment of placentation is possible using this technique.

Localisation of Hodgkin's disease and lymphomas by 67-gallium substraction scanning.

67Ga-subtraction scan was found to be useful and a promising new method for the pre-treatment evaluation of the patient with Hodgkin's disease or non-Hodgkin's lymphoma. The scan appeared to be most accurate in the neck, chest, and axillary regions. It appears to offer a means of increasing the accuracy of evaluating the abdomen, the para-aortic and pelvic regions. It may be a useful method for the follow-up to detect recurrences. It was an easily performed, safe, non-invasive test, well tolerated and accepted by patients.

[Localization of Hodgkin's disease and non-Hodgkin lymphoma by means of 67 gallium subtraction scintigraphy]. / Lokalisation von Morbus Hodgkin und Non-Hodgkin-Lymphomen mit Hilfe der 67Gallium-Subtraktions-Szintigraphie.

67Ga-subtraction scan was found to be useful and a promising new method for the pre-treatment evaluation of the patient with Hodgkin's disease or non-Hodgkin's lymphoma. The scan appeared to be most accurate in the neck, chest, and axillary regions. It appears to offer a means of increasing the accuracy of evaluating the abdomen, the paraaortic and pelvic regions. It may be a useful method for follow-up to detect recurrences. It was an easily performed, safe, non-invasive test, well tolerated and accepted by patients.

67Ga-subtraction scanning in Hodgkin's disease and lymphomas.

Recently a new method was described, the 67Ga subtraction scanning method. 67Ga accumulates in neoplastic and inflammatory tissue. The subtraction method was applied for evaluating 38 patients with Hodgkin's disease and non-Hodgkin's lymphoma. The preliminary experiences are described. It was found that the diagnostic accuracy is comparable to that of 67Ga scanning. The subtraction method offers potential improvement of the accuracy for equivocal scans, but further technological refinement is needed before the method can be widely applicable.