The effects of physical exercise on plasma levels of relaxin, NTproANP, and NTproBNP in patients with ischemic heart disease

The insulin-like and vasodilatatory polypeptide relaxin (RLX), formerly known as a pregnancy hormone, has gained interest as a potential humoral mediator in human heart failure. Controversy exists about the relation between plasma levels of RLX and the severity of heart failure. The present study was designed to determine the course of RLX, atrial, and brain natriuretic peptide (NT-proANP and NT-proBNP) during physical exercise in patients with ischemic heart disease (IHD) and to relate hormone levels to peak cardiac power output (CPO) as a measure of cardiopulmonary function with prognostic relevance. 40 patients with IHD were studied during right-heart-catheterization at rest and during supine bicycle ergometry. RLX, NTproBNP, and NTproANP were determined before, during exercise, and after recovery. NT-proANP and NT-proBNP levels increased during maximal charge, and recovery while RLX levels decreased. Cardiac power output at maximal charge correlated inversely with NTproANP and NTproBNP but positively with RLX. Patients with high degree heart failure (CPO < 1.96 W) had higher NTproANP and NTproB-NP and lower RLX levels than patients with low degree heart failure. While confirming the role of NTproANP and NTproBNP as markers for the severity of heart failure, the present data do not support the concept that plasma levels of RLX are related to the severity of myocardial dysfunction and that systemic RLX acts as a compensatory vasodilatatory response hormone in ischemic heart disease

Interinstitutional variations in mode of birth after a previous caesarean section : a cross-sectional study in six German hospitals

Aims: Regional and interinstitutional variations have been recognized in the increasing incidence of caesarean section. Modes of birth after previous caesarean section vary widely, ranging from elective repeat caesarean section (ERCS) and unplanned repeat caesarean section (URCS) after trial of labour to vaginal birth after caesarean section (VBAC). This study describes interinstitutional variations in mode of birth after previous caesarean section in relation to regional indicators in Germany. Material and methods: A cross-sectional study using the birth registers of six maternity units (n=12,060) in five different German states (n=370,209). Indicators were tested by χ2 and relative deviations from regional values were expressed as relative risks and 95% confidence intervals. Results: The percentages of women in the six units with previous caesarean section ranged from 11.9% to 15.9% (P=0.002). VBAC was planned for 36.0% to 49.8% (P=0.003) of these women, but actually completed in only 26.2% to 32.8% (P=0.66). Depending on the indicator, the units studied deviated from the regional data by up to 32% [relative risk 0.68 (0.47–0.97)] in respect of completed VBAC among all initiated VBAC. Conclusions: There is substantial interinstitutional variation in mode of birth following previous caesarean section. This variation is in addition to regional patterns

Kontroversen um die Sekundärprävention von spontanen Frühgeburten

Preterm birth is one of the major global health problems and part of the Millennium Development goals because of the associated high number of perinatal or neonatal mortality and long-term risks of neurodevelopmental and metabolic diseases. Transvaginal sonography has meanwhile been established as a screening tool for spontaneous preterm birth despite its relatively low sensitivity when considering only the cervical length. Vaginal progesterone has been shown to reduce prematurity rates below 34 weeks in a screening population of singleton pregnancies. Up to now, no positive long-term effect could be demonstrated after 2 years. It seems to have no benefit to prolong pregnancies after a period of preterm contractions and in risk patients without cervical shortening. Meta-analyses still demonstrate conflicting results dependent on quality criteria used for selection. A cerclage is only indicated in singleton pregnancies with previous spontaneous preterm birth and a combined cervical shortening in the current pregnancy. Nevertheless, the short- and long-term outcome has never been evaluated, whereas maternal complications may be increased. There is no evidence for a prophylactic cervical cerclage in twin pregnancies even in cases with cervical shortening. Emergency cerclage remains an indication after individual counseling. The effect of a cervical pessary in singleton pregnancy seems to be more pronounced in studies where a few investigators with increasing experience have treated and followed the patients at risk for preterm birth. Mainly in twin pregnancies, pessary treatment seems to be promising compared to other treatment options of secondary prevention when the therapy is started at early stages of precocious cervical ripening. At present, several international trials with the goal to reduce global rates of prematurity are in progress which will hopefully allow to specify the indications and methods of intervention for certain subgroups. When trials are summarized, prospective meta-analyses carry a lower risk of bias than the meanwhile uncontrolled magnitude of retrospective meta-analyses with conflicting results.Frühgeburten gehören zu den wichtigsten Gesundheitsproblemen weltweit und gehören wegen der damit verbundenen hohen perinatalen und neonatalen Mortalitätsraten und der Langzeitrisiken für neurologische Entwicklungsstörungen und Stoffwechselkrankheiten zu den Millenniums-Entwicklungszielen. Obwohl die Sensitivität der transvaginalen Sonografie bei der Messung der zervikalen Länge relativ niedrig ist, hat sich diese Methode als Screeninginstrument bei der Prävention von spontanen Frühgeburten etabliert. Die vaginale Verabreichung von Progesteron hat in einer Population werdender Mütter mit Einlingsschwangerschaft die Frühgeburtsraten vor der 34. Woche nachweislich verringert. Bislang wurden aber keine positiven Langzeitwirkungen nach 2 Jahren nachgewiesen. Es scheint, dass die Herauszögerung der Schwangerschaft nach einiger Zeit mit vorzeitigen Wehen sowie bei Risikopatientinnen ohne Zervixverkürzung keine Vorteile bietet. Die Ergebnisse von Metaanalysen sind nach wie vor widersprüchlich und hängen von den gewählten Qualitätskriterien ab. Eine Cerclage ist nur bei Einlingsschwangerschaften nach spontaner Frühgeburt in einer vorherigen Schwangerschaft verbunden mit einer Zervixverkürzung in der aktuellen Schwangerschaft indiziert. Die kurz- und langfristigen Auswirkungen wurden nicht untersucht, obwohl sie möglicherweise zu einer Erhöhung der mütterlichen Komplikationen führen könnten. Es gibt keine Hinweise, dass die prophylaktische zervikale Cerclage vorteilhaft ist bei Zwillingsschwangerschaften, selbst bei Frauen mit Zervixverkürzung. Je nach individueller Beratung mag eine Not-Cerclage indiziert sein. Die Wirkung eines zervikalen Pessars in Einlingsschwangerschaften war ausgeprägter in Studien, bei denen die Untersucher zunehmende Erfahrung hatten bei der Behandlung und Nachbetreuung von Frauen mit einem höheren Risiko für Frühgeburtlichkeit. Im Vergleich zu anderen Optionen für die Sekundärprävention scheint die Behandlung mit einem Pessar erfolgversprechend, vor allem bei Zwillingsschwangerschaften, wenn früh mit der Behandlung begonnen wird, d. h. in den ersten Stadien einer vorzeitigen Zervixreifung. Zurzeit laufen mehrere internationale Studien, die alle das Ziel haben, die Frühgeburtsraten weltweit zu reduzieren, und die hoffentlich weitere Hinweise auf die Indikationen und Interventionsmethoden für bestimmte Untergruppen liefern werden. Bei der Zusammenfassung von Studien wiesen prospektive Metaanalysen ein niedrigeres Verzerrungsrisiko auf als die inzwischen unkontrollierte Menge retrospektiver Metaanalysen mit ihren widersprüchlichen Ergebnissen

The differential diagnosis of fetal facial tumors: A case report of a neonatal granular cell tumor (GCT)

Cranio-cervico-facial tumors are rare. While ultrasound is the gold-standard method for diagnosing these anomalies, three-dimensional ultrasound and prenatal magnetic resonance imaging are complementary tools for reaching a precise diagnosis. Hemangiomas, meningoceles, proboscis lateralis, skin appendages and other fetal tumors are the main differential diagnoses. The prenatally assumed diagnosis of these malformations can change postnatally, with the ready identifcation of additional clinical features. We present a case of prenatally suspected proboscis lateralis. This diagnosis was revised postnatally to a facial hemangioma. The tumor did not regress with β-blocker therapy for 5 months, and so a biopsy was then performed, which showed it was a granular cell tumor (GCT). This was later successfully excised, with clear margins. This case is important because there has been only one reported case of neonatal GCT, and because it shows that even with technologically advanced prenatal diagnostic methods, reaching the correct diagnosis can still be challenging. Keywords: Fetal facial tumors, Granular cell tumor, Neonatal GC

The B-mode sonographic evaluation of the post-caesarean uterine wall and its methodology: a study protocol

Aim: The aim of this study is to utilize the niche measurement guidelines outlined by Jordans et al. in order to establish normal values and accurate description of caesarean section scars in a normal population. After defining the normal distribution, abnormal pregestational scar characteristics will be identified for predicting adverse pregnancy outcomes. Methods: This is a prospective observational multicenter clinical study where women with a history of only one caesarean section and yet open family planning are enrolled. The uterine length, cervical length, niche length, niche depth, niche width, residual myometrial thickness, endometrial thickness, scar to internal os distance, anterior myometrial thickness superior and inferior to the scar and the posterior myometrial thickness opposite the scar, superior and inferior to it are measured in a pregestational uterus. The lower uterine segment is measured over a length of 3 cm during subsequent pregnancy and followed up until delivery. Results: Data from 500 patients will yield normal distribution curves for all predefined measurements. Establishing a correlation between deviations from the normal measures and adverse events would be instrumental for counseling women regarding subsequent pregnancy and mode of delivery. Conclusion: This study will demonstrate the changes of the post-caesarean scar from a non-pregnant uterus until delivery and can confirm the importance of the scar characteristics in predicting pregnancy outcome

Does the appearance of the cutaneous scar after cesarean section reflect the residual myometrial thickness?

Purpose!#!The aim of this study is to utilize the Manchester scar scale (MSS) and ultrasound in investigating the association between uterine wall defects and cutaneous scar characteristics after cesarean section (CS).!##!Methods!#!This is a prospective cohort study. The degree of myometrial loss was quantified by calculating a residual myometrial thickness (RMT) ratio as a percentage of RMT to the pre-cesarean anterior uterine wall thickness. Cutaneous scar assessment was performed according to the MSS. Spearman's correlation and the Kruskal-Wallis test with a cut-off value of p &amp;lt; 0.05 were used for statistical analysis.!##!Results!#!Two hundred forty seven women, of which 2.4% had an Asian, 3.6% an Afro-American, 82% a Caucasian and 12% a Mediterranean background, were recruited. The RMT ratio ranged between 11.9 and 100% with a median of 55.8% and an average of 56%. MSS scores ranged from 4 to 13 with a median of 5 and an average of 6. Spearman's correlation between MSS and RMT ratio show a rho of - 0.01 with a p value of 0.8. The correlation between MSS and RMT ratio within the four ethnical groups showed a p value between 0.3 and 0.8 and a rho between 0.8 and - 0.8. The Kruskal-Wallis test showed an eta!##!Conclusion!#!CS laparotomy scars heal differently between ethnical groups, but generally with satisfying results. Ethnicity does not affect myometrial healing and scar appearance does not reflect myometrial healing after CS. Thus, separate uterine sonographic assessment is recommended

The effect of the onset of labor on the characteristics of the cesarean scar

Objective: To assess the effect of cesarean section (CS) timing, elective versus unplanned, on the residual myometrial thickness (RMT) and CS scars. Methods: This is a prospective single-blinded observational cohort study with 186 observations. Patients indicated to undergo first singleton CS were preoperatively recruited. Exclusion criteria were history of repeated CS, vertical hysterotomy, diabetes, and additional uterine surgeries. Sonographic examination was performed for assessing the RMT ratio, the presence of a niche, fibrosis, and the distance from the scar to the internal os (SO) 1 year after CS. Power analysis was performed with 0.05 α, 0.1 β, and all statistical analyses were conducted with Stata®. Results: Wilcoxon rank-sum test for the association between CS timing, RMT ratio and SO showed Z values of −0.59 and −4.94 (P = 0.553 and P 0.99 and P = 0.268, respectively). Linear regression between SO and the extent of cervical dilatation showed a −0.45 β (95% confidence interval −0.68 to −0.21) and a 10.22-mm intercept (P < 0.001). Conclusion: RMT is independent of the timing of CS, but the SO distance shows a negative linear relationship with the cervical dilatation

Anatomy of the sonographic post-cesarean uterus

Purpose: We aim to describe the sonographic uterine anatomy after a cesarean section (CS), test the reproducibility of predefined measurements from the BSUM study, and report the distribution of these measurements. Methods: This is a descriptive observational study where 200 women with a history of only one CS were recruited 12–24 months postoperatively. A 5–13 MHz micro-convex transvaginal transducer was used for the acquisition of volumetric datasets for evaluating the CS scars. We defined 15 distinct measurements including the residual myometrial thickness (RMT). RMT ratio was calculated as a percentage of RMT to the assumed pre-cesarean anterior uterine wall thickness. A P value below 0.05 is utilized for significant statistical analysis. Results: Patients were included on average 18.5 months post-cesarean. The uterus was anteflexed in 82.5% and retroflexed in 17.5%. Myometrial defects at the site of CS manifest in two forms, either as a niche or as fibrosis. Patients are classified into four groups: those with isolated niches (45%), combined niches and fibrosis (38.5%), isolated fibrosis (11%), and lacking both (5%). The median RMT ratio for these groups was 63.09, 40.93, 59.84, and 100% with a standard deviation of 16.73, 12.95, 16.59, and 0, respectively. The interclass correlation coefficient (ICC) remained above 0.9 for all distinct measurements among these groups except for those of RMT, where ICC varied between 0.47 and 0.96. The RMT ratio shows a constant ICC at 0.94 regardless of the group. Conclusion: The post-cesarean uterus is often anteflexed, and a myometrial loss of about 50% is normally expected. The pattern of this loss is in the form of a predominantly sharp-edged and echogenic niche, fibrosis, or a combination of both. The proposed RMT ratio takes these changes into consideration and results in a reproducible quantification. We hypothesize that different adverse outcomes could be attributed to the different scar patterns