Fetal neck tumors – antenatal and intrapartum management

In this review article we describe the ante- and perinatal management of fetal neck tumors. Although there are rare congenital anomalies, the clinical consequences for the fetus may be fatal and include airways obstruction, heart insufficiency, pulmonary hypoplasia and cosmetic effect. The right management allows to decrease the fetal and neonatal mortality and morbidity associated with the disease. It includes intrauterine therapy in some cases, mostly in a goitrus hypothyroidism of the fetus, but firstly, an assessment of the fetal airways patency with a subsequent, eventual Ex-Utero Intrapartum Treatment (EXIT)

Megacystis in a fetus – description of 3 clinical cases

Abstract 3 cases of fetal megacystis have been described in the article. In each clinical situation the pathology was diagnosed in the first half of the pregnancy. The authors have attempted to present clinical management in congenital megacystis. Key elements in the further diagnostics of megacystis in a fetus include invasive procedures to exclude or confirm chromosomal aberrations in fetus and detailed ultrasound anatomy scan of the fetus. The possibility of prenatal treatment of megacystis (placement of vesico-amaniotic shunt) is the source of considerable controversy. Biochemical assessment of fetal kidney function seems to be the most important element in evaluation of patients before introducing the intrauterine therapy. Contraindication for the prenatal treatment may be not only fetal aneuploidy but also serious maternal pregnancy complications, such as severe preeclampsia accompanied by deterioration of renal function and increasing ascites. The decision to place the shunt in a fetus should be made bearing in mind that although it significantly reduces the risk of perinatal death, it may unfortunately fail to improve renal function of the affected child

Wyniki badań dopplerowskich u płodów matek z wczesną i późną postacią stanu przedrzucawkowego

Objectives: Comparison of fetal umbilical and middle cerebral artery flow between early- and late-onset preeclampsia. Material and methods: Our study was conducted among 50 patients with preeclampsia in the third trimester of pregnancy and included 30 women with early-onset and 20 with late-onset disease. Early-onset preeclampsia (EOP) and late-onset preeclampsia (LOP) were defined as onset of the disease before and after 34 weeks of gestation, respectively. Doppler examinations of the fetal umbilical and middle cerebral artery were performed in all patients. Pulsatility Index (PI) and cerebral-umbilical ratio (CUR) were measured each time. Results: Mean value of the umbilical artery PI was significantly higher in fetuses of patients with EOP in comparison to LOP, whereas mean PI value in MCA was significantly lower in fetuses from the group with EOP than LOP. The percentage of abnormal results of fetal Doppler examinations, both in the umbilical artery and middle cerebral artery, was significantly higher in EOP than in LOP. The same tendency was observed for CUR. Conclusions: 1. Early-onset preeclampsia is characterized by significantly higher degree of placental insufficiency than late-onset disease. 2. The obtained results indicate a significant, pathological role of the placenta in early-onset preeclampsia. 3. Pathophysiological differences between early- and late-onset preeclampsia lead to different clinical approach to patients, depending on the type of the disease, including emphasis on Doppler examination in the early-onset preeclampsia. 4. The presence or absence of placental insufficiency in pregnancy complicated by preeclampsia seems to determine the clinical course of the disease, thus allowing for an alternative classification of the condition into placental and maternal preeclampsia.Cel pracy: Ocena przepływów krwi w tętnicy pępowinowej oraz tętnicy środkowej mózgu u płodów matek z wczesną i późną postacią stanu przedrzucawkowego. Materiał i metody: Badaniem objęto 50 pacjentek ze stanem przedrzucawkowym w 3. trymestrze ciąży, w tym 30 z wczesną postacią PE i 20 z późną postacią choroby. Wczesną postać stanu przedrzucawkowego diagnozowano w sytuacji jej rozpoznania przed 34 tygodniem ciąży, a późną gdy była diagnozowana w lub po 34 tygodniu. U wszystkich pacjentek dokonano oceny przepływu krwi w tętnicy pępowinowej i środkowej mózgu płodu. Każdorazowo dokonywano pomiaru wartości wskaźnika pulsacji (PI) oraz obliczano wskaźnik mózgowo-pępowinowy. Wyniki: Średnia wartości wskaźnika pulsacji w tętnicy pępowinowej była istotnie wyższa u płodów matek z wczesną PE aniżeli u płodów kobiet z późną postacią stanu przedrzucawkowego. Z kolei wartość wskaźnika mózgowo-pępowinowego CUR była istotnie niższa u płodów z ciąż powikłanych wczesną postacią choroby w porównaniu do późnej PE. We wczesnej postaci PE stwierdzono istotnie wyższy odsetek nieprawidłowych wyników badania dopplerowskiego zarówno w tętnicy pępowinowej jak i tętnicy środkowej mózgu płodów. Powyższy trend dotyczył także wartości CUR w obu grupach. Wnioski: 1. Wczesną postać stanu przedrzucawkowego cechuje wyraźnie większy stopień zaburzeń przepływu łożyskowego aniżeli późną postać choroby. 2. Uzyskane rezultaty badań dopplerowskich wskazują na istotną rolę patologii łożyska głównie we wczesnej postaci stanu przedrzucawkowego. 3. Odmienności patofizjologiczne między wczesną a późną postacią stanu przedrzucawkowego skłaniają do różnicy w podejściu klinicznym do pacjentek, w zależności od postaci choroby, w tym do położenia nacisku na badanie dopplerowskie płodu głównie we wczesnej postaci schorzenia. 4. Obecność lub brak zaburzeń przepływu łożyskowego w ciąży powikłanej stanem przedrzucawkowym wydaje się ściśle determinować obraz kliniczny choroby co tym samym sugeruje możliwość alternatywnego podziału choroby na postać matczyną i łożyskową

Zastosowanie badania dopplerowskiego w drugiej połowie ciąży

The article is a review of the literature on the use and clinical applicability of Doppler examination in the second half of pregnancy. Nowadays, despite its accessibility, Doppler ultrasound in pregnancy is often contraindicated. At the same time, the is no evidence of clinical utility of Doppler studies in a low-risk pregnancy. The main indications for Doppler examinations in pregnancy include intrauterine growth restriction (IUGR), suspicion of fetal anemia, and complications of monochorionic twin pregnancy. As far as IUGR is concerned, Doppler allows to diagnose IUGR associated with placental insufficiency and to differentiate IUGR from small for gestational age fetuses (SGA). Doppler is also very useful in making the decision about the time of delivery of IUGR fetuses. The assessment of the peak systolic velocity in the middle cerebral artery (PSV-MVA) reduced the rate of invasive procedures due to fetal anemia by approximately 70%. Complications of the second half of pregnancy which are indications for Doppler ultrasound include selective IUGR, TTTS and TAPS. Similarly to the first trimester, the mid-trimester assessment of the blood flow in the uterine arteries plays an important role in the prediction of preeclampsia and IUGR, especially early-onset forms of these complications.Praca jest przeglądem piśmiennictwa na temat zastosowania i przydatności klinicznej badania dopplerowskiego w 2. połowie ciąży. Mimo ogólnie łatwej aktualnie dostępności do badań dopplerowskich w ciąży, istnieją ścisłe wskazania do ich wykonania. Jednocześnie nie wykazano przydatności klinicznej badania dopplerowskiego w ciąży fizjologicznej. Głównym wskazaniem do wykonania badania dopplerowskiego jest ciąża powikłana wewnątrzmacicznym ograniczeniem wzrastania płodu (IUGR), podejrzenie niedokrwistości u płodu oraz powikłania ciąży bliźniaczej jednokosmówkowej. W odniesieniu do ograniczenia wzrastania płodu, badanie dopplerowskie pozwala między innymi na rozpoznanie IUGR uwarunkowanego niewydolnością łożyska oraz różnicowanie IUGR ze zbyt małą masą u płodu z zachowanym prawidłowym potencjałem wzrastania (SGA). Badanie dopplerowskie jest też niezwykle pomocne w podejmowaniu decyzji co do momentu zakończenia ciąży powikłanej IUGR. Jeśli chodzi o diagnostykę niedokrwistości u płodu, wykorzystanie oceny maksymalnej prędkości skurczowej w tętnicy środkowej mózgu (PSV MCA), pozwoliło zmniejszyć o ok. 70% częstość procedur inwazyjnych wykonywanych z tego powodu. Powikłaniami ciąży bliźniaczej jednokosmówkowej będącymi wskazaniem do badania dopplerowskiego płodów są: selektywny IUGR, TTTS oraz TAPS. Podobnie jak w 1. trymestrze ciąży, także w jej połowie, ocena przepływów w tętnicach macicznych znajduje przydatność w predykcji wystąpienia IUGR i stanu przedrzucawkowego, zwłaszcza ich wczesnych postaci

Preeclampsia – two manifestations of the same disease

Abstract Preeclampsia, due to its complicated and unexplained pathophysiology, remains one of the most difficult subjects in modern maternal-fetal medicine. Despite of the fact that diagnostic criteria of preeclampsia are clear and homogenous, the clinical manifestation of the disease, the prognosis and the frequency of maternal and fetal complications differ considerably among the cases. The aim of the review was to emphasize the heterogenous character of preeclampsia which may be manifested in two different clinical forms – a maternal and placental one. The maternal preeclampsia occurs mostly in multiparous patients with known risk factors of preeclampsia such as: 1) insulin resistance, 2) diabetes mellitus, 3) dyslipidemia, 4) obesisty, and 5) chronic hypertension. The placental form of the disease is more common among nulliparous women without prior risk factors of preeclampsia. The main clinical differences between the two forms are: 1) an earlier onset of placental preeclampsia in most cases, and 2) a more frequent presence of placental insufficiency in placental preeclampsia. The following article focuses on both forms of preeclampsia in the aspect of different clinical manifestations, different prognosis, as well as different management of the disease

Assessment of uterine arteries Doppler in the first half of pregnancy in women with thrombophilia

Objectives: Assessment of uterine artery blood flow in women with congenital thrombophilia and antiphospholipid syndrome (APS) in the first half of pregnancy Material and methods: Uterine arteries blood flow was assessed in a Doppler examination in 20 women with thrombophilia (15 with congenital thrombophilia, 5 with APS) at 12 and 20 weeks gestation at the Division of Reproduction, Poznan University of Medical Sciences, between 2000 and 2012 The control group consisted of 20 multiparous pregnant women with no history of pregnancy complications. All patients with thrombophilia received enoxaparin or enoxaparin and aspirin before enrollment into the study. Patients from the control group did not receive any antithrombotic prophylaxis. The mean Pulsatility Index (PI) of both uterine arteries and the presence or the absence of the “notch” was assessed, both at 12 and 20 weeks gestation in each patient from the study and from the control groups. Results: Mean PI values in the uterine arteries at 12 weeks in patients with thrombophilia and in controls were 1.82 (1.00-3.13) and 1.52 (1.30-1.88), respectively (p=0.08). Mean PI value in the uterine arteries was 1.27 (0.61-2.48) in women with thrombophilia at 20 weeks, which turned out to be significantly higher (p=0.026) than in the control group 1.07 (0.8-1.24). The bilateral “notch” was found at 12 weeks gestation in 40% of patients with thrombophilia vs. 0% in the control group (p=0.03). There was no significant difference between the groups in this parameter at 20 weeks. Conclusions: 1. An increased impedance of flow was found in the uterine arteries in patients with thrombophilia at 12 and 20 weeks gestation in spite of antithrombotic prophylaxis. 2. Thrombotic episodes in patients with thrombophilia cannot be explained solely by the presence of placental thrombosi

Ocena stężenia czynników antyangiogennych, triglicerydów, glukozy, insuliny oraz SHBG u kobiet z dwoma postaciami stanu przedrzucawkowego

Objectives: Assessment of serum concentrations of antiangiogenic factors, triglycerides, glucose, insulin and SHBG in women with two forms of preeclampsia (placental and maternal). Material and methods: The study was conducted among 30 patients with placental preeclampsia and 20 women with maternal form of the disease. All patients were hospitalized at the Division of Reproduction, Poznan University of Medical Sciences, between 2010-2012. The placental form of preeclampsia was diagnosed in cases when Doppler signs of placental insufficiency were present. The maternal type of the disease was diagnosed in the absence of coexisting markers of placental insufficiency in the Doppler study. ELISA was used to determine the concentrations of antiangiogenic factors (sFlt-1 and sEng). Results: The placental form of preeclampsia was diagnosed significantly earlier than maternal type of the disease. In women with placental preeclampsia the gestational age at delivery and newborn birth weight were significantly lower than in patients with maternal preeclampsia. IUGR incidence (expressed as a percentage) was significantly higher in patients with placental preeclampsia as compared to the women with maternal form of the disease. Serum concentrations of sFlt-1 and sEng were significantly higher in women with placental preeclampsia. No differences in concentrations of glucose, insulin, triglycerides and SHBG were found between groups. Conclusions: 1. The Two Stage Model of preeclampsia, characterized by increased concentrations of antiangiogenic factors in maternal blood secondary to decreased placental blood flow, seems to better explain the pathophysiology of the placental form of preeclampsia than the maternal one. 2. Late onset of clinical symptoms in maternal preeclampsia, lower incidence of IUGR, as well as lower concentrations of antiangiogenic factors in maternal blood, do not indicate the primary role of placental pathology in the pathogenesis of the disease. 3. In spite of no difference in metabolic abnormalities in third trimester of pregnancy between two types of preeclampsia, the patophysiology of the two forms of the disease seems to be different. 4. The obtained results of metabolic markers in women with two types of preeclampsia justify the need of further studies in this field in first trimester of pregnancy.Cel pracy: Ocena stężenia czynników antyangiogennych (sFlt-1 i sEng), triglicerydów, glukozy, insuliny oraz SHBG w surowicy krwi kobiet w dwóch postaciach stanu przedrzucawkowego-łożyskowej i matczynej. Materiał i metody: Badania przeprowadzono w 3. trymestrze ciąży u 30 pacjentek z łożyskową postacią stanu przedrzucawkowego (PE) oraz u 20 kobiet z matczynym typem choroby. Wszystkie ciężarne objęte badaniem były hospitalizowane w Klinice Rozrodczości Uniwersytetu Medycznego w Poznaniu, w latach 2010-2012. Podstawą do rozpoznania postaci łożyskowej choroby było występowanie objawów spełniających kryteria diagnostyczne stanu przedrzucawkowego oraz obecność wykładników dopplerowskich niewydolności łożyska. Postać matczyną stanu przedrzucawkowego rozpoznawano przy braku obecności wykładników niewydolności łożyska w badaniu dopplerowskim. Do oznaczenia stężenia w surowicy sFlt-1 i sEng wykorzystano metodę ELISA (R&D Systems). Wyniki: Łożyskowa postać stanu przedrzucawkowego była rozpoznawana istotnie wcześniej niż postać matczyna choroby. U pacjentek z postacią łożyskową PE ciąża trwała istotnie krócej, masa urodzeniowa noworodków była istotnie niższa, a odsetek IUGR wyższy niż u kobiet z postacią matczyną choroby. Stężenie sFlt-1 oraz sEng było istotnie wyższe u pacjentek z łożyskową postacią choroby w porównaniu do kobiet z matczynym typem stanu przedrzucawkowego. Poziom triglicerydów, glukozy, insuliny, SHBG nie różniły się istotnie pomiędzy dwoma badanymi grupami. Wnioski: 1. Dwuetapowy mechanizm stanu przedrzucawkowego, w którym podwyższonemu stężeniu czynników antyangiogennych towarzyszy istotne zaburzenie przepływu łożyskowego wydaje się lepiej tłumaczyć patofizjologię postaci łożyskowej aniżeli postaci matczynej choroby. 2. Późny początek występowania objawów klinicznych w postaci matczynej stanu przedrzucawkowego i mniejsza częstość IUGR, współistniejące z niższym poziomem czynników antyangiogennych we krwi, poddają w wątpliwość pierwotny udział patologii łożyska w mechanizmie powstawania choroby. 3. Z punktu widzenia prawdopodobnego patomechanizmu ich powstawania, obie postacie schorzenia mają charakter odmiennych jednostek chorobowych, mimo braku różnic pomiędzy postaciami w stopniu zaburzeń metabolicznych w 3. trymestrze ciąży. 4. Uzyskane wyniki markerów zaburzeń metabolicznych u kobiet z dwoma postaciami stanu przedrzucawkowego uzasadniają podjęcie badań w tym zakresie w I trymestrze ciąży

Polyhydramnios — frequency of congenital anomalies in relation to the value of the amniotic fluid index

Objectives: The aims of our study were to assess the correlation between the amniotic fluid index (AFI) value and the frequency and type of fetal anomalies. Material and methods: The material included 94 patients at the third trimester of pregnancy, 60 with mild polyhydramnios, 19 with moderate one, and 15 with severe one. Polyhydramnios was diagnosed if AFI was > 24 cm. All patients were divided into three groups based on the value of AFI: 1) mild polyhydramnios with AFI between 24.1 and 29.9 cm, 2) moderate polyhydramnios with AFI between 30–34.9 cm, and 3) severe polyhydramnios with AFI ≥ 35 cm. Results: The incidence of fetal malformations correlated significantly with the degree of polyhydramnios and was the highest in patients with severe polyhydramnios (53.3%, p = 0.002). Congenital malformations of the gastrointestinal tract were the most frequent fetal anomalies in the whole group of patients (5.3%). Trisomy 18 was the most frequent aneuploidy found in women with polyhydramnios (2.1%). Conclusions: The incidence of fetal congenital anomalies significantly increases with the degree of polyhydramnios, being most frequent in severe one and rather rare in a mild one. Congenital malformations of the gastrointestinal tract were the most frequent anomalies in patients with polyhy­dramnios, especially in women with severe polyhydramnios

Follow-up of children with antenatally diagnosed idiopathic polyhydramnios

Objectives: The aim of our work was to assess the development of children with antenatally diagnosed idiopathic poly- hydramnios, over 12 months from the end of pregnancy.  Material and methods: The study included 91 healthy pregnant patients with idiopathic polyhydramnios. Diagnostic tests results and perinatal medical history were obtained retrospectively. Parents of children were contacted by phone and by mail. The answers were obtained from 64 (70%) parents. For statistical analysis SigmaStat3.5 software was used.  Results: Ninety six percent of parents declared that in their opinion the development of children was normal. Abnormali- ties were found in 44% of the children. Thirty percent of neonates demonstrated mild abnormalities which may be due to organic or functional neuromuscular disorders: abnormal muscle tone, speech apparatus and development disorders, swallowing and breathing problems (manifested as vomiting, excessive regurgitation, idiopathic apnoeas).  Isolated small malformations were diagnosed in 12 (19%) children. Two children (3%) with SGA were diagnosed with genetic syndromes. More than one of the abnormalities described above were diagnosed in 14% of children. Gestational age at the time of polyhydramnios diagnosis and its severity were not prognostic factors for abnormalities. Seventy percent of newborns were male.  Conclusions: Despite the subjectively positive assessment of the development of children by the majority of parents, groups of common disorders requiring long-term follow-up have been identified. Functional disorders of the gastrointestinal tract, CNS and the group of neuromuscular disorders may be responsible for idiopathic polyhydramnios. SGA with co-existing idiopathic polyhydramnios is associated with the risk of genetic diseases. The more frequent incidence of idiopathic poly- hydramnios in male fetuses requires further research.

Perinatal and cardiovascular outcomes in a pregnant patient with Marfan syndrome

A 25-year-old primigravida with Marfan syndrome (MFS) was admitted at 36 weeks of gestation (WOG)