Yun Hyeon Kim

The effect of a Foley catheter balloon on cervical ripening

The Foley catheter balloon may affect cervical ripening through changes in biochemical mediators by immunoassay and immunohistochemistry, when it is used for pre-induction cervical ripening. The aim of the study was to evaluate the changes in the biochemical mediators from the extra-amniotic space and immunohistochemistry in ripened cervical tissue after the insertion of a Foley catheter balloon (FCB) for pre-induction cervical ripening. A total of 18 pregnant women with a Bishops score < 6, who were undergoing labour induction, were evaluated in this prospective study. The FCB was irrigated with 10 ml of phosphate buffered saline and the irrigant was collected 0, 2, 4 and 8 h after placement of the FCB or until spontaneous expulsion of the FCB occurred. Irrigant specimens were also collected from 10 spontaneous labouring (SL) women in the active phase of labour. The levels of interleukin (IL)-6, IL-8, matrix metalloproteinase (MMP)-8 and NO were measured. Cervical specimens were obtained from 12 women, including four undergoing induction; four SL and four non-pregnant (NP) women. Immunohistochemical staining was performed to localise hyaluronic acid synthase (HAS)-1, IL-6, IL-8, MMP-8, endothelial nitric oxide synthase (eNOS) and inducible NOS (iNOS). Results showed that the levels of IL-6, IL-8, and MMP-8 significantly increased over time in FCB group (p < 0.01). In the immunohistochemical analysis of cervical tissues, immunoreactivity of HAS-1 in the after FCB group was stronger than any of the other groups. The protein expressions of IL-6, IL-8, MMP-8, eNOS and iNOS were more prominent in the after FCB and SL groups than in the NP and the before FCB groups. iNOS was only observed in the after FCB and SL groups. It was concluded that FCB may affect cervical ripening through changes in biochemical mediators by immunoassay and immunohistochemistry, when it is used for pre-induction cervical ripening.

The Relationship among N-Terminal Pro-B-Type Natriuretic Peptide, High-Sensitivity C-Reactive Protein and Infarct Size in Patients with Acute ST-Elevation Myocardial Infarction.

Background and Objectives We sought to investigate the relationship between levels of high-sensitivity C-reactive protein (hs-CRP) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) and the infarct size and left ventricular (LV) volume after acute myocardial infarction (MI). Subjects and Methods Eighty-six patients with acute ST-elevation MI underwent delayed enhancement multidetector computed tomography immediately after they underwent percutaneous coronary intervention to determine the infarct size. LV function and remodeling were assessed by echocardiography. Hs-CRP and NT-proBNP were measured at admission, 24 hours and two months later. Results Both hs-CRP and NT-proBNP at 24 hours showed a positive correlation with infarct size and a negative correlation with LV ejection fraction at the baseline and two months later. NT-proBNP at two months correlated with infarct size, LV ejection fraction, and LV end diastolic and systolic volume indices at two months. In patients with high NT-proBNP levels at 24 hours and two months, infarct size was larger and LV ejection fraction was lower. NT-proBNP was higher in patients who developed LV remodeling at two months: 929 pg/mL vs. 134 pg/mL, p=0.002. In contrast, hs-CRP at two months showed no relationship to infarct size, LV function, or LV volumes at two months. Conclusion Elevated hs-CRP level 24 hours after the onset of acute MI is associated with infarct size and LV dysfunction, whereas elevated levels of NT-proBNP 24 hours and two months after the onset of acute MI are both correlated with infarct size, LV dysfunction, and LV remodeling.

Comparison of the clinical and quality-of-life outcomes after the inside-out TVT-O procedure with or without concomitant transvaginal gynaecological surgery

The study was undertaken to compare the clinical and quality-of-life (QoL) outcomes of the inside-out transobturator vaginal tape (TVT-O)-only procedures and TVT-O procedures with concomitant transvaginal gynaecological surgery for the treatment of stress urinary incontinence (SUI). A review of charts from January 2006 to March 2010 identified 305 patients with urodynamic stress incontinence for whom we performed the TVT-O. Of the initial 305 patients, 272 (89.2%) were re-examined for complications 1 month, 4 months, 1 year and 2–4 years postoperatively (122 TVT-O only; 150 TVT-O + other transvaginal gynaecological surgery). They were also evaluated with the Urogenital Distress Inventory Questionnaire (UDI-6) and the Incontinence Impact Questionnaire (IIQ-7) 1–4 years after the procedure. The median follow-up was 37.3 months. The success rate was 89.3% in the TVT-O-only group vs 93.3% in the TVT-O with concomitant gynaecological surgery group (p =0.729). The QoL score was quite good for 91.8% of the TVT-O-only patients and for 96.7% of the TVT-O with concomitant gynaecologic surgery patients (p =0.405). In conclusion, gynaecological operations performed concomitantly with the TVT-O procedure do not affect the clinical and QoL outcomes of the TVT-O procedure.

PP177. The usefulness of gestation-corrected hyperuricemia as a predictor of the development of preeclampsia on subsequent pregnancy.

INTRODUCTION Hyperuricemia has been described commonly in preeclamptic pregnancies, often preceding the diagnosis of preeclampsia and historically was used as a diagnostic marker of preeclampsia. OBJECTIVES The aim of this study was to determine the usefulness of uric acid to predict the preeclampsia on subsequent pregnancy. METHODS The retrospective chart review was done. The pregnant women who had previous preeclampia or gestational hypertension and checked serum uric acid were enrolled in this study. Fifty-eight women were collected. Hyperuricemia was defined as being one standard deviation above the gestation-specific mean . And we used uric acid z-scores ([serum uric acid value - gestation specific mean]/standard deviation of the population) to account for gestation-specific alterations in uric acid and tested this as a continuous variable. Linear regression analysis was used to assess the relationship between gestation-corrected hyperuricemia and development of preeclampsia on subsequent pregnancy. RESULTS Of 58 women, nineteen had the development of recurrent preeclampsia (37.5%). Linear regression analysis showed that the absence or presence of gestation-corrected hyperuricemia was not associated with the development of preeclampsia on subsequent pregnancy (p=0.353, 95% CI 0.418-11.520). And gestation-specific uric acid z-score as a continuous variable did not show any association with the prediction of preeclampsia on subsequent pregnancy (p=0.353, 95% CI 0.087-2.394). CONCLUSION Gestation-corrected hyperuricemia does not predict the development of preeclampsia on subsequent pregnancy.

P05.08: A case of fetal oropharyngeal immature teratoma

We present the case of a 32 year old para 1 woman pregnant with monochorionic twins. Acrania was diagnosed in one twin at at 12 weeks gestation in association with an absent stomach bubble. Both babies were karyotypically normal. This pregnancy was later complicated by twin–twin transfusion syndrome (TTTS) with the affected fetus as the donor. This combination confounded both the diagnosis and grading of severity of TTTS as a lack of swallowing by the acranial donor twin led to normal amniotic fluid volume measurements. An assessment of twin to twin transfusion was therefore made purely on the basis of Doppler ultrasound. After referral to the tertiary centre selective laser coagulation of the placental vessels and cord was done with the demise of the anencephalic donor twin. At 30 weeks gestation spontaneous precipitate labour ensued with a first stage lasting only 25 minutes, and resulting in the birth of a live 1270 g female infant. Apgar scores were low at delivery and the baby was transferred to the intensive care baby unit. The main problem of twins discordant for acraniaanencephaly was reduced following laser treatment with salvage of the normal twin in this case. The concerns are that preterm birth risk appears unchanged generally despite improved care. There is currently no universally agreed policy for managing this condition in monochorionic twins. There is therefore a need for multi-centred studies to help maximise survival of the normal twin and prevent majore morbidity.

OP32.05: Evaluation of Bishop score, length, volume and gray-scale histogram of the cervix as predictors of successful induction

Objectives: Using a dedicated novel software (SonoVCAD labor), we analyzed 3D-volumes of fetal head just prior attempted instrumental delivery in theatre to see if we can define a ‘cut-off value’ based on various sonographic parameters that would predict a successful vaginal birth. Methods: We performed an offline analysis of 11 fetal head volumes stored immediately prior attempted instrumental delivery using GEs novel 3D software ‘SonoVCAD labor’. We related head direction angle, midline angle, progression distance and angle of progression with the success or failure to achieve vaginal birth. Results: Four out 11 women had Caesarean section (two without trial and two following failed trial). Seven women had successful instrumental delivery. Head direction angle of > 95 degrees was associated with successful vaginal birth. All cases that ended with Caesarean section had head direction angle of less than 95 degrees. For angle of progression, a cut off of 160 degrees or more predicted successful outcome for all cases. All cases with CS had angle of progression < 160 degrees. As regards progression distance, all cases with vaginal birth had distance > 60 mm prior to delivery. However, one woman who ended with CS had distance of 44 mm. Midline angle ranged from 28–148 degrees and did not predict the outcome in women with CS. Conclusions: Head direction angle > 95 degrees and angle of progression > 160 were predictors of successful instrumental delivery. The midline angle and progression distance did not correlate well with the outcome of the trial. We will continue analyzing these parameters in future cases to assess their diagnostic accuracy. Given this is a relatively new technique, more data are needed to elucidate the clinical contribution of this new tool and the best way to use it.

P16.17: Combined treatment of KCl and methotrexate in cervical pregnancy at 12 weeks gestational age: a case report

Caesarean section scar pregnancy is a rare form of ectopic pregnancy. Implantation takes place at the site of the uterine scar where trauma may have created a false passage in the myometrium. It can be difficult to diagnose on ultrasound. If the diagnosis is not made early there can be serious implications for future fertility and potentially life threatening consequences. A variety of different management approaches have been described. We present the case of a 31 year old woman gravida 4 para 2 (both caesarean sections) who was referred to our unit from A&E with lower abdominal pain and vaginal bleeding following 6 weeks amenorrhoea. Initial ultrasound at 6+3/40 showed a gestation sac of 22 × 14 × 16 mm in the lower third of uterus with no yolk sac or fetus seen. A diagnosis of probable inevitable miscarriage was made. Repeat ultrasound 1 week later showed enlargement of the gestation sac (27 × 20 × 25 mm), still low in the uterus with no yolk sac or fetal pole. The patient was scanned by a consultant gynaecologist ten days later at 9/40. A diagnosis of caesarean section scar pregnancy was made with no myometrium visible anteriorly. The diagnosis of caesarean section scar ectopic pregnancy must be suspected in a pregnant woman with a uterine scar when early ultrasound shows a gestational sac that is implanted anteriorly in the lower third of the uterus. Although sometimes difficult to distinguish from intrauterine pregnancy, the diagnosis is possible by ultrasound but requires a high level of suspicion and expertise. Early intervention is necessary to avoid serious complications.

SILDENAFIL IN CONJUNCTION WITH ANGIOTENSIN-CONVERTING ENZYME INHIBITOR IS EFFECTIVE IN LIMITING INFARCT EXPANSION IN A PORCINE MODEL OF ANTERIOR MYOCARDIAL INFARCTION

Background: Sildenafil, a selective inhibitor of phosphodiesterase type 5, induces cardioprotection against myocardial ischemia-reperfusion injury through activation of cGMP-dependent protein kinase. However, there are few reports on its effect in limiting infarct expansion after acute myocardial infarction (AMI). We investigated whether sildenafil could reduce myocardial infarct size (IS) in a porcine model of AMI, especially in combination with angiotensin converting enzyme inhibitor (ACEI).

P05.06: Antenatal diagnosed occipital calcification: a case of craniosynostosis

Premature ossification and closure of the cranial sutures results in the abnormal shape and size of the skull. This can cause compression on cranial nerves and increased pressure on growing brain. In most cases, only one suture is affected and the condition is isolated and sporadic. However, in a minority of cases, closure of multiple sutures is possible and associated anomalies are present. The most frequent craniosynostosis is due to closure of the sagittal suture, which is responsible for about half of the cases, resulting in an elongated head (scaphocephaly). The second most frequent type is due to closure of the coronal suture that results in a very flat, recessed forehead (brachycephaly). We report a rare case of craniosynostosis in the sagittal and bilateral lambdoid sutures. Ultrasound examinations were performed in the ACCUVIX XQ (Medison, Seoul, Korea). Antenatal sonographic finding was normal except occipital calcification. Fetus occipital area was calcified and protrudent. Fetal brain MRI was checked and it was not detected any pathology finding. Cesarean section was performed at 37 weeks gestation. 2990g, male was born. He had abnormal scalp shape and small head. Craniosynostosis with sagittal and both lambdoid sutures and small cranial volume was detected in brain 3 dimensional CT. But brain MRI was not any evidence of brain anomaly. So we report our experience with a brief review of literature.

OP19.01: Atosiban, magnesium sulfate and ritodrine therapy for preterm labor: effects on uterine, fetal umbilical and middle cerebral artery Doppler parameters in the first 24 hours

Background: Cardiovascular abnormalities are common in the recipient twin in TTTS. In the donor, except for altered umbilical arterial flow, no gross cardiovascular changes are typically seen. Selective laser photocoagulation therapy (SLPT) improves outcome and can reverse many of the cardiovascular abnormalities noted in the recipient, however its impact on the donor twin heart has not been extensively studied. Objective: To investigate the effects of SLPT for TTTS on the cardiovascular status of the donor twin. Methods: Pre and post-operative fetal echos from 54 patients who underwent SLPT for TTTS Stage 2 or higher from June 2007 to February 2009 were reviewed. Cardiothoracic ratio (CTR), Doppler tricuspid and mitral E and A peak inflow velocities, umbilical artery (UA) and middle cerebral artery (MCA) pulsatility indices (PI), and myocardial performance indices (MPI) of the donor twin, were compared before and after SLPT. Presence or absence of pericardial effusion (PE) and tricuspid or mitral regurgitation were also noted. Results: CTR increased significantly as did mitral and tricuspid valve velocities, suggesting an increase in volume load. UA PI increased, but MCA PI remained unchanged. In select donors RV MPI increased substantially, however there was no difference for the group as a whole. Postoperatively, over 20% of donors developed a significant PE; nearly 50% developed tricuspid or mitral regurgitation. Conclusions: Important cardiovascular abnormalities develop in the donor twin following SLPT. The origin of these findings are unclear, but may be related to the insult of acute, rapid volume load in a previously volume depleted fetus. Serial fetal echo follow up of both donor and recipient for cardiovascular abnormalities after SLPT is warranted.