Zdenek Zizka

Hysteroscopy after uterine fibroid embolization in women of fertile age

Aim:  Uterine artery embolization for fibroids is a controversial issue for women with incomplete reproductive plans. Ovarian failure and uterine infection are the most dreaded complications of this procedure. The purpose of the present study was to assess the types and the frequency of intrauterine abnormalities and the histological features of the endometrium after embolization.

Fetal Anemia, Thrombocytopenia, Dilated Umbilical Vein, and Cardiomegaly due to a Voluminous Placental Chorioangioma

We report a case of voluminous placental chorioangioma diagnosed by ultrasound and color Doppler imaging during the 20th week of pregnancy. The size of the tumor was enlarging progressively (up to 10 cm in the 32nd week), and during this time the signs of fetal intrauterine volume overload and blood cell consumption, such as cardiomegaly, umbilical vein dilation, hydramnios, anemia, and thrombocytopenia, were observed. In the 32nd week of pregnancy, the signs of uteroplacental insufficiency and fetal hypoxia appeared; therefore, the pregnancy was terminated by cesarean section, and a female infant weighing 1,870 g was delivered. She was discharged, fully recovered, after 48 days. Histopathological examination of the placental tumor showed a benign, vascular-type chorioangioma.

Prenatally Diagnosable Differences in the Cellular Immunity of Fetuses with Down’s and Edwards’ Syndrome

Introduction: Lymphocyte subpopulations are identified by the uniform CD classification (Cluster of Differentiation) and can be accurately differentiated with monoclonal antibodies using the method of flow cytometry. With the aid of cordocentesis it is possible to perform studies on the status and development of cellular immunity as early as in the second trimester of pregnancy. Objective: To compare lymphocyte subpopulations present in fetuses with chromosomal abnormalities (Down’s syndrome (DS), Edwards’ syndrome (ES)) and fetuses with normal karyotype. Study Design: Prospective observational study. Methods: We examined a total of 61 pregnant women with an average age of 31.5 years (20– 46 years). Results: In fetuses with DS we found a significant decrease in B lymphocytes (CD19),a decrease in the subpopulations of multi-reactive B-cells (CD5+CD19+, B-CLL),and a decrease in the index of CD4/CD8 and class II HLA-DR. In contrast, the representation of NK cells expressing /CD3-CD (16 + 56)+/ was greatly increased. In ES we found a decrease in T lymphocytes (CD3), a decrease in T-helper lymphocytes (monocytes CD4), a decreased index of CD4/CD8 and a greater representation of NK cells /CD3-CD (16 + 56)+/. Conclusion: We determined the normal values of lymphocyte subpopulations in physiological fetuses. We demonstrated that the immunological defect of the affected fetuses is already present antenatally, and can be reliably diagnosed in the second trimester of pregnancy.

Changes in Hemostatic Variables Induced by Estrogen Replacement Therapy: Comparison of Transdermal and Oral Administration in a Crossover-Designed Study

Aim: The purpose of this study was to determine the changes of biochemical risk factors for thromboembolisms using different administration routes of early estrogen replacement therapy. Methods: In a 12-week prospective, randomized crossover trial, estradiol was administered orally (2 mg daily) or transdermally (0.05 mg daily). Forty-five healthy early postmenopausal women were included into the study within 12 weeks after hysterectomy and oophorectomy. Forty-one women (age 49 ± 6 years) completed the study, and their data were analyzed. The hemocoagulation parameters were determined prior to beginning of the study and at the end of each treatment period, separated by a 1-week washout period. Results: After oral therapy, the average tissue factor pathway inhibitor levels decreased statistically significantly (p < 0.0001) from 87.5 ± 39.1 to 68 ± 37.49 ng/ml. The plaminogen activator inhibitor-1 levels also decreased statistically significantly (p = 0.001) after the oral estrogen therapy from 11.39 ± 12.02 to 5.0 ± 5.27 IU/l. These changes were also significant when compared with the nonsignificant changes after the transdermal therapy. No significant changes occurred in the levels of D-dimers. After both treatment methods, the antithrombin III and fibrinogen levels decreased, but within their physiological ranges. Conclusions: Oral administration of estrogen statistically significantly reduced the tissue factor pathway inhibitor and plasminogen activator inhibitor-1 levels when compared with the transdermal route. These changes cannot be unambiguously considered risky, and the zero change of D-dimers suggests that there was no activation of the coagulation cascade. We consider the neutral effect of the transdermal therapy more beneficial.

ABO fetomaternal compatibility poses a risk for massive fetomaternal transplacental hemorrhage

Objective. Severe fetomaternal transplacental hemorrhage increases the risk of fetal anemia. In the third trimester, the syncytiotrophoblast becomes thinner, especially in areas where it comes into intimate contact with villous capillaries, and forms a vasculosyncytial membrane. Our aim was to determine whether ABO compatibility puts the fetus at a greater risk of severe fetomaternal hemorrhage. Design. Case study. Setting. A tertiary care center. Sample and methods. Between 2003 and 2007, we evaluated eight cases of severe fetomaternal transfusion. The Kleihauer‐Betke test was used for diagnosis of fetomaternal hemorrhage. We evaluated blood group compatibility between the mother and fetus and assessed the perinatal outcome. The Fischers factorial test was used for testing a hypothesis. Results. The incidence of adverse outcomes following transplacental hemorrhage was 75% (six of eight). There were two perinatal deaths and four infants were affected by post‐hypoxic damage of varying severity. Fetomaternal ABO compatibility was present in seven of the eight cases. The risk of severe fetomaternal hemorrhage was significantly increased when there was ABO compatibility between the mother and fetus. This was associated with a very poor perinatal outcome. Conclusion. We recommend that resuscitation in utero by intrauterine transfusion should be considered before the 33rd week of gestation in cases of severe fetal anemia. In later gestation, urgent cesarean section is required with adequate resuscitation of the newborn.

Prenatal Diagnosis of Occipital Dermal Sinus Associated with Hemangioma Using Ultrasound and MRI

Objective: We report a case of prenatal diagnosis and postpartum management of a subcutaneous tumor without intracranial communication. Methods: An occipital tumor without intracranial communication was found on ultrasound scan in the 21st week of pregnancy. Using MRI, the diagnosis was confirmed. Subcutaneous localization of the tumor was verified and communication with intracranial space excluded. Results: The newborn was delivered spontaneously at term and underwent a successful surgical procedure 5 months postpartum. Conclusion: The prenatal diagnosis allowed differentiation between a communicating neural tube defect with poor prognosis, and a manageable extracranial subcutaneous tumor. The precise diagnosis of uncomplicated dermal sinus was possible only after the histological evaluation of the tumor confirmed occipital dermal sinus associated with hemangioma.

P27.15: Inadvertent intra‐arterial administration during intraumbilical transfusion as a cause of severe bradycardia and fetal hypoxia

We performed an arterial embolization at 29 weeks. We observed the disappearing of vascular flow inside the tumor, without any modification on placenta flow. Delivery at 41 weeks gestation: normal newborn (3250 g). We consider that the procedure could be less iatrogenic than others. We could be more selective than laser and less toxic than alcohol. We didn’t observe any bleeding after needle removal. The procedure could be performed after a complete vascular cartography (contribution of the 3D Doppler imaging), a perfect preparation of Histoacryl and be careful not to create a venous embolization. We suggest to do an prospective study, to have an answer about the timing of the procedure, to evaluate the risk and the advantages.

OC052: Ultrasound at 20–22 weeks of pregnancy increases the rate of detection of Down syndrome above that of combined first‐trimester screening alone

treatment. The enhanced area of 62 lesions i 66.7% j was a bit larger than that of the 2D measurement. In 3 cases, the post-treatment CEUS showed no obvious ablated area within the tumor, who were given another HIFU treatment once with increased therapeutic dosage. The average ablation volume (without enhancement in CEUS) of the leiomyomas after HIFU treatment was 82.9% ± 19%. The mean volume of the tumors was 60.0% ± 29.1% (P < 0.05) decreased compared with that of the pre-treatment, 6 months later. Symptoms of all cases improved or disappeared after treatment. There was no serious side-effect of the treatment observed. Conclusions: CEUS can visualize the circulatory condition of the tumor and thus play an important role in HIFU treatment of uterine leiomyomas.

OP10.06: Risk of miscarriage and pregnancy outcome after multifetal pregnancy reduction (MFPR)

Objectives: To determine whether the risk of fetal loss following trans-abdominal multifetal pregnancy reduction (TA-MFPR) of a monochorionic twin pair is similar to the one in dichorionic pairs. Study Design: A retrospective review of all TA-MFPR performed in our institution (1999–2007) was conducted. The procedurerelated fetal loss, defined as pregnancy loss prior to completion of 24 weeks, in pregnancies involving reduction of a monochorionic pair i.e. ‘‘Mono group’’ was compared to the loss rate in all other TA-MFPR i.e. ‘‘Non-mono group’’. This comparison was further stratified according to the specific pre and post reduction number of fetuses. Additionally, association between the number of needle insertions performed and the procedure related fetal loss was sought. Results: 394 TA-MFPR were eligible for analysis and an overall loss rate of 2.5% (10 of 394) was detected. The procedure related loss in the ‘‘Mono’’ and ‘‘Non-mono’’ groups as well as the impact of the pre and post reduction number of fetuses on the fetal outcome is displayed in table 1. Information regarding number of needle insertions was available on 182 TA-MFPR of which in 22 ‘‘Nonmono’’ and 16 ‘‘mono’’ cases the same needle insertion was used to reduce more than a single fetus. The loss rate for single, two and three needle insertions was 3/165, 0/11 and 1/6 respectively (pnon significant). Conclusions: Fetal loss following TA-MFPR is independent of the chorionicity of the pair reduced. Additionally, we noted a trend suggesting an increased risk for fetal loss with increased number of needle insertions. Since monochorionic twins carry an increased pregnancy-related complication rate, it is our practice to attempt reduction of such pairs, preferably by using a single needle insertion. This can be achieved by a careful selection of the needle pathway to reach both fetuses.

OP04.17: Correlation between the myocardial performance index in the left ventricle and the gestational age in physiological pregnancy

and Doppler flow velocity waveforms of Umbilical Artery, Middle Cerebral artery, Ductus Venosus and Uterine arteries. Patients with adverse outcomes were excluded and all the women with normal outcomes were included for data analysis. Every two gestational weeks patients were grouped and for these groups, the 5th, 50th and 95th percentiles were calculated for the FO, and DA Peak systolic velocity (PSV) and Pulsatility Index (PI). Results: Gestation – specific reference ranges were constructed for the fetal intrauterine shunts. In normal pregnancies, PI of FO decreased and PI of DA was relatively constant with advancing gestation. However, the PSV of FO and DA increased linearly with gestational age. Conclusion: Reference ranges for fetal central intrauterine shunts have been established which may enhance our understanding of fetal compromise and aid in evaluating management of complications like fetal growth restriction as well as congenital cardiac malformations.