Ervin Hruby

Calcification of the fetal heart - Four case reports and a literature review

Calcification of the heart and vessels in fetuses is a rare condition. It may be dystrophic or metastatic. An extremely rare form of vascular calcification has been termed ‘idiopathic arterial calcification of infancy’, which is inherited in an autosomal recessive pattern. We report four cases of myocardial calcifications of different origin diagnosed in utero. The correct diagnosis is very important in regard to genetic counselling. Copyright

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/μL 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.

Congenital Heart Diseases in Twin Pregnancies

Objective: To find connection between the type of congenital heart malformations and twin pregnancies. Method: Retrospective analysis of data of fetal cardiology database between 1 January 1996 and 30 November 2003. Results: In single pregnancies 455 and in twin pregnancies 31 severe congenital heart malformations were diagnosed prenatally. In monozygotic twin pregnancies 36% of heart malformations were pulmonary stenosis and 45% endocardial fibroelastosis, which is significantly higher than in single pregnancies. In dizygotic twin pregnancies Ebstein malformation was significantly more frequent than in single pregnancies. With the exception of Ebstein malformation in dichorionic and dizygotic twin pregnancies the cardiac malformations were similar to the ones in single pregnancies. Conclusions: The twin pregnancy alone can be considered as indication for fetal echocardiography. The type of congenital heart malformations detected in monochorial twin pregnancies was different from those found in single, dizygotic or dichorionic twin pregnancies. Chorionicity seems to be more important than zygosity.

Assessment of serum interleukin-6 with a rapid test. The diagnosis of neonatal sepsis can be established or ruled out

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 maternal and fetal outcome of 122 triplet pregnancies

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.

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

Abstract 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.

Maternal age as a risk factor in triplet pregnancy

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.

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.

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.