Andrée Grignon

Placenta percreta: Balloon occlusion and embolization of the internal iliac arteries to reduce intraoperative blood losses☆☆☆★

Obstetric hemorrhage is still a potential cause of maternal mortality and morbidity. Angiographic embolization techniques have been described in cases of postcesarean bleeding, vaginal wall hematomas, cervical ectopic pregnancies, and postpartum bleeding to control persistent bleeding from pelvic vessels. We describe two cases of pregnancy complicated with placenta percreta. Balloon occlusion and embolization of the hypogastric arteries were performed during the cesarean section and hysterectomy, resulting in a remarkable reduction in intraoperative blood loss. Balloon occlusion and embolization of the internal iliac arteries significantly reduce intraoperative blood losses.

Incidence and risk factors of catheter-related deep vein thrombosis in a pediatric intensive care unit: A prospective study

OBJECTIVE To estimate the incidence and to characterize risk factors for central venous catheter (CVC)-related deep vein thrombosis (DVT) in a pediatric intensive care unit. STUDY DESIGN Consecutive children admitted to a pediatric intensive care unit who required a CVC for more than 48 hours were examined by Doppler ultrasonography of the catheterized vein at days 2, 4, 6, or 7 after insertion and weekly thereafter until CVC removal. RESULTS The incidence of CVC-related DVT was 18.3% (17 of 93) (95% confidence interval = 10.2% to 25.8%). Thromboses were diagnosed within the first 4 days of catheter placement for 15 of 17 CVC-related thromboses. Multivariate analysis showed that risk factors most predictive of CVC-related DVT were presence of a cancer (odds ratio = 17.23, 95% confidence interval = 1.5 to 194) and young age (odds ratio for age = 0.72, 95% confidence interval = 0.54 to 0.96). CONCLUSION The frequency of CVC-related DVT is substantial in pediatric intensive care units. Risk is highest during the 4 days after insertion and decreases thereafter. The clinical impact, optimal prevention, and therapy of these thromboses remain to be determined.

Blunt Pancreatic Injuries in Children: The Role of Percutaneous External Drainage in the Treatment of Pancreatic Pseudocysts

During the past 10 years, 26 cases of blunt pancreatic trauma were diagnosed in our institution. In 42.3% (11/26) the accident was bicycle-related. Seventy-three percent of patients were seen within 48 hours of injury. The most frequent clinical presentations included abdominal pain, tenderness and vomiting. Diagnosis of pancreatic injury was suggested by hypermylasemia in most cases. Associated trauma was seen in seven patients (26.9%) and it was intraabdominal in four (15.3%). Computerized tomography (CT) scan is the single most useful radiologic investigation in evaluating pancreatic trauma. Ultrasound, although less accurate than CT scan in determining the severity of the initial injury, is useful in the evaluation and treatment of pancreatic pseudocysts. Pancreatic pseudocysts developed in ten patients. Spontaneous resolution occurred in five (50%). In three patients, percutaneous external drainage (PED) was successful in treating pancreatic pseudocysts without complications or recurrence at 11, 19, and 31 months. PED is a suitable form of treatment in selected cases of pancreatic pseudocysts. Results in children are better than in the adult population, probably due to the absence of primary pancreatic pathology. We believe that PED should be considered the primary therapeutic procedure for traumatic pancreatic collections prior to more invasive surgical treatment, when there is no evidence of pancreatic duct transection on CT scan.

Potential value of fetal echocardiography in the differential diagnosis of twin pregnancy with presence of polyhydramnios-oligohydramnios syndrome

OBJECTIVE Our purpose was to establish whether index values of cardiac performance could discriminate between the twin-twin transfusion syndrome and placental insufficiency as the etiology of the polyhydramnios-oligohydramnios sequence in monochorionic diamniotic twins. STUDY DESIGN Thirteen monochorionic diamniotic twin pregnancies with ultrasonographic evidence of polyhydramnios-oligohydramnios sequence had a complete echocardiography. The etiology was confirmed postnatally: placental insufficiency in eight pairs and the twin-twin transfusion syndrome in five. Intertwin comparisons were made for the following cardiac parameters: cardiothoracic index, end-diastolic thickness of the ventricular walls and septum, aortic and pulmonary artery Doppler peak velocities, ejection and acceleration times, left ventricular shortening fraction, and combined cardiac output and output indexed to fetal weight. RESULTS All five recipient twins had thickened ventricular walls. The left ventricular shortening fractions and outputs were significantly increased in the donor twin with twin-twin transfusion syndrome and normal in placental insufficiency. CONCLUSION In twin-twin transfusion syndrome the donor twin shows evidence of a hyperdynamic cardiac state. Intertwin comparison of cardiac parameters, especially the left ventricular shortening fraction, can be considered a useful tool in diagnosing the different etiologies of the polyhydramnios-oligohydraminos sequence.

Gastroschisis: are prenatal ultrasonographic findings useful for assessing the prognosis?

Objective. The objective of this study was to assess various prenatal patterns in correlation with survival and the occurrence of complications of antenatally recognized gastroschisis (G).Materials and methods. We retrospectively studied 34 cases of G. Mortality and morbidity in the postnatal period were assessed and correlated with the prenatal presence or absence of: (1) bowel and/or stomach dilatation, (2) thickening and/or hyperechogenicity of the intestinal wall, (3) meconium peritonitis (in the abdomen) before 20 weeks of gestation, (4) asymmetrical bowel dilatation, and (5) associated malformations. Morbidity took into account the length of hospitalization and the number of surgical procedures.Results. The overall survival rate was 94 %. Neither bowel nor stomach dilatation was significantly correlated with mortality. However, evidence of intestinal dilatation greater than 17 mm had a positive predictive value of 67 % for atresia, with a negative predictive value of 86 %. Thickening and/or hyperechogenicity of the bowel wall were not significantly associated with mortality. Meconium peritonitis before 20 weeks and asymmetrical bowel dilatation were not statistically significant because of the small sample size. Twelve patients (35.3 %) had postnatal complications, with a mean hospital stay of 127 days. Outcome was not modified by the mode of delivery. Associated extradigestive anomalies were present in 20.6 % of cases. Chromosomal anomalies were not seen.Conclusion. The prognosis of prenatally detected G is excellent despite the frequency of small bowel atresia (67 %) in the group with postnatal complications. Meconium peritonitis before 20 weeks of gestation and/ or asymmetrical bowel dilatation also appear to be indicators of atresia (2/4, 50 %) or high morbidity (3/4,75%).

Imaging features of type 1 hereditary tyrosinemia: a review of 30 patients.

Hereditary tyrosinemia type 1, a common genetic disorder in the province of Quebec, is characterized by a deficiency of fumarylacetoacetate hydrolase. In this autosomal recessive disorder of tyrosine metabolism, the accumulation of succinyiacetone leads to neurologic crises, acute and chronic liver failure, complex renal tubulopathy, rickets and a hemorrhagic syndrome. Liver transplantation has dramatically modified the spontaneous course of this lethal disease. The present paper describes the imaging features of tyrosinemia in 30 patients followed from 1980 to 1995 at Hôpital Sainte-Justine, Montreal, Canada.

Prenatal Diagnosis of Cloverleaf Skull: Watch the Hands!

Pfeiffer syndrome is an extremely rare autosomal-dominant condition whose prenatal diagnosis has only been reported 6 times, mainly on the basis of a fetal cloverleaf skull deformity. Three types have been described, each with a different prognosis. This case report stresses the need to thoroughly analyze the fetus and particularly the fetal hands in case of prenatal observation of a cloverleaf skull. The discovery of characteristic hand abnormalities allowed the early prenatal detection of type 2 Pfeiffer syndrome in our patient.

Nonsurgical management of neonatal adrenal abscess.

The fifteenth case of neonatal adrenal abscess is reported. It is the first case successfully diagnosed with needle aspiration and treated with percutaneous drainage.

Prenatal ultrasound screening of congenital heart disease in the general population: general concepts, guidelines, differential diagnoses.

Abstract Congenital heart diseases (CHDs) carry a high prevalence rate in the general population (0.8%–1%). Most fetal CHDs occur in patients without any risk factors. The prenatal recognition of CHD has major impacts on the pregnancy and its outcome. The aforementioned data justify prenatal ultrasound (US) screening of CHD in the general low-risk population. As demonstrated in the literature, the application of an extended basic US cardiac examination improves the detection of CHD, in particular the conotruncal anomalies. The stepwise method suggested for fetal heart US screening during the mid–second trimester sonogram is based on 4 routine axial views of heart and great vessels: (1) a transverse view of the superior abdomen, (2) a 4-chamber view, (3) a 3-vessel view, and (4) a transverse view of the aortic arch. This protocol can be obtained rapidly because these scans are easy to perform. Despite the fact that the sequential segmental approach universally used in the postnatal diagnosis of CHD is not specifically addressed here, the detected anomalies can be categorized according to these views, and a short differential diagnosis proposed. Abnormal cardiac and/or vascular landmarks shown on these key scans should lead to a referral in the fetal cardiac center for a more precise evaluation, as well as for counseling.

The Fetal Chest

The study of the fetal chest is an important component of the standard fetal US examination. Congenital thoracic malformations may be responsible for fetal or neonatal death due to mediastinal compression or respiratory distress (Hubbard and Crombleholme 1998a). The discovery of a fetal thoracic malformation modifies the perinatal management and implies a transfer to a specialized neonatal department. The discovery of a fetal thoracic anomaly may also lead to the diagnosis of a polymalformation syndrome or to a chromosomal anomaly (Goldstein 2000).