Hormonalna terapia zastępcza a choroby układu sercowo-naczyniowego

The results of large randomized trials such as the Women's Health Initiative (WHI), Heart and Estrogen / Progestin Replacement Study (HERS) or Estrogen Replacement and Atherosclerosis Study (ERAS) as well as the Million Women Study (MWS) which does not meet criteria RCT, concerning, among others the impact of HRT on breast cancer risk, thromboembolism, or the aging processes in the central nervous system caused the recent big confusion in the medical community , causing distrust about the safety and advisability of HRT in menopausal women. The paper presents an overview of the available, current literature on HRT. It was found that HRT should not be used in both primary and secondary prevention of coronary heart disease Great expectations was associated with an earlier initiation of therapy, before the advent of atherosclerosis - but there is currently no conclusive data about its role in the primary prevention of coronary disease. Oral HRT increases the risk of thromboembolic events - that is why you should prefer the form of a transdermal. HRT may increase the risk of ischemic stroke (but early initiation of therapy does not increase the risk of stroke) and should not be used in the primary prevention of stroke.Wyniki dużych randomizowanych badań klinicznych, takich jak Women’s Health Initiative (WHI), Heart and Estrogen/Progestin Replacement Study (HERS), czy Estrogen Replacement and Atherosclerosis Study (ERAS), jak również niespełniającego kryterium RCT dużego badania Million Women Study (MWS), dotyczących m.in. wpływu HTZ na ryzyko raka piersi, powikłania zakrzepowo-zatorowe, czy procesy starzenia w ośrodkowym układzie nerwowym wywołały w ostatnim czasie duże zamieszanie w środowisku lekarskim, powodując nieufność, co do bezpieczeństwa i celowości stosowania HTZ u kobiet menopauzalnych. Praca przedstawia przegląd dostępnej, aktualnej literatury na ten temat. Stwierdzono, ze nie należy stosować HTZ zarówno w pierwotnej, jak i wtórnej prewencji choroby niedokrwiennej serca. Duże nadzieje wiąże się z wcześniejszym rozpoczęciem terapii, przed pojawieniem się zmian miażdżycowych – obecnie brak jest jednak jednoznacznych danych o jej roli w pierwotnej prewencji choroby niedokrwiennej. Doustna HTZ zwiększa ryzyko zdarzeń zakrzepowo-zatorowych – dlatego należy preferować formę transdermalną. HTZ może zwiększać ryzyko udaru niedokrwiennego (ale wczesne rozpoczęcie terapii nie wpływa na zwiększenie ryzyka udaru). HTZ nie należy stosować w pierwotnej prewencji udaru mózgu

Aktualne wytyczne dotyczące postępowania w zespole TTTS

The paper presents current views and recommendations for pregnancy complicated by TTTS. The symptoms that should attract our attention during the first-trimester ultrasound, i.e. CRL asymmetry, NT >95th percentile, or 20% or more of the NT difference between the fetuses, absent or reversed A wave in DV, and TV regurgitation, are discussed and presented. Similarly, symptoms that should attract our attention in the second trimester, such as amniotic fluid volume imbalance, asymmetry in the size of the urinary bladders, abdominal circumferences discordance, inter-twin membrane folding, membranous attachment of the donor’s umbilical cord, different placental echogenicity, and abnormal Doppler measurements, are listed. The paper presents the principle of monitoring based on ultrasound examination, including Doppler studies. The necessity and usefulness of echocardiography is underlined. It is also stressed that the frequency of monitoring depends on the severity of hemodynamic changes and the check-up rate varies from once a week to daily monitoring in extreme cases. This paper presents a variety of therapeutic options, including conservative management, septostomy, amnioreduction, laser and selective fetoreduction. Taking into account the level of disease severity, stages I and V can be managed conservatively. Fetoscopic laser coagulation of anastomoses, which can be used almost in all stages of TTTS (I-IV), remains to be the treatment of choice. However, the current level of evidence does not yet allow us to determine whether laser coagulation increases or reduces the risk of neurodevelopmental delay and mental retardation in children, as compared to other types of therapy. Amnioreduction may be recommended in cases when laser therapy is unavailable or as first-line therapy before transporting the patient to the intrauterine therapy center.W pracy przedstawiono aktualne poglądy i rekomendacje dotyczące postępowania w zespole TTTS. Omówiono objawy, które powinny zwrócić naszą uwagę w badaniu USG w I trymestrze, do których należy asymetria CRL płodów, NT > 95 percentyla lub 20% i większa różnica NT pomiędzy płodami, brak lub wsteczna fala A w DV, niedomykalność zastawki TV. Przedstawiono również objawy, które powinny zwrócić naszą uwagę w II trymestrze ciąży. Należy do nich: dysproporcja objętości płynu owodniowego, asymetria wielkości pęcherzy moczowych, dysproporcja wielkości obwodów brzucha, fałdowanie się przegrody międzypłodowej, błoniasty przyczep pępowiny dawcy, rożna echogeniczność łożyska, nieprawidłowe wyniki badań dopplerowskich. W pracy przedstawiono zasady monitorowania w oparciu o badanie USG z uwzględnieniem badania dopplerowskiego. Zwrócono również uwagę na konieczność i użyteczność monitorowania echokardiograficznego. Podkreślono, że częstość monitorowania uzależniona jest od stopnia zaawansowania zaburzeń hemodynamicznych i waha się od kontroli 1 raz na tydzień do codziennego monitorowania w skrajnych przypadkach. Praca prezentuje rożne opcje postępowania terapeutycznego z uwzględnieniem postępowania zachowawczego, septostomii, amnioredukcji, laseroterapii oraz selektywnej fetoredukcji. Uwzględniając stopnie zaawansowania stwierdzono, że w I i V można wdrożyć postępowanie zachowawcze. Leczeniem z wyboru jest fetoskopowa laserowa koagulacja anastomoz, która może być stosowana prawie we wszystkich stadiach zaawansowania (I-IV). Jednak obecny poziom dowodów nie pozwala nam na stwierdzenie, czy laserowa koagulacja wpływa na wzrost lub na zmniejszenie ryzyka wystąpienia opóźnienia rozwoju neurologicznego oraz upośledzenia umysłowego u dzieci w porównaniu z innymi rodzajami terapii. Amnioredukcja może być zalecana w sytuacji, kiedy terapia laserowa jest niedostępna lub jako terapia pierwszego rzutu przed transportem pacjentki do ośrodka terapii wewnątrzmacicznej

Zmiany prędkości przepływu krwi w naczyniach żylnych kończyn dolnych w ciąży powikłanej niewydolnością żylną

Introduction: Venous insufficiency in pregnancy is associated witch an increased risk of complications. Objectives: The aim of the study was to analyse the venous system changes of the lower limbs during pregnancy and puerperium with or without venous insufficiency. Material and methods: The research was carried out on pregnant women divided into two groups according to the presence or lack of venous insufficiency. The venous system was examined four times: between 11-14th, 18-22nd, 28-32nd gestational week and at the 6th week of puerperium. The doppler examination included the measurement of the blood flow velocity in selected deep veins of the lower limbs: common femoral vein, the superficial femoral vein and the popliteal vein. Consecutively, the changes in the blood flow velocity during pregnancy and puerperium were compared between groups and finally to the results obtained in the 1st trimester. Results: The analysis of the blood flow showed that the blood flow velocity was statistically lower in the group with venous insufficiency. Velocity changes in time showed, in majority of cases, a substantial reduction in the blood flow velocity in the third trimester in both groups. This blood flow velocity increases during the puerperium and does not differ from those observed in the first trimester. Thus, the tendency of changes in the blood flow velocity were similar in character in both groups. Conclusions: The pregnancy related changes in venous system of lower extremities showed the reduction of blood flow velocity with advancing gestational age and were more evident in pregnancy complicated by venous insufficiency.Wstęp: niewydolność żylna w ciąży związana jest ze zwiększonym ryzykiem powikłań. Cele: Celem pracy była analiza zmian w układzie żylnym kończyn dolnych w czasie ciąży i połogu, z lub bez niewydolności żylnej. Materiał i metody: Badania przeprowadzono wśród ciężarnych, które podzielono na dwie grupy w zależności od obecności lub braku niewydolności żylnej. Układ żylny badano czterokrotnie: między 11-14, 18-22, 28-32 tygodniem ciąży oraz w 6. tygodniu połogu. Badanie dopplerowskie obejmowało pomiar prędkości przepływu krwi w wybranych żyłach głębokich kończyn dolnych: wspólnej żyle udowej, powierzchownej żyle udowej i żyle podkolanowej. Kolejno, zmiany prędkości przepływu krwi w okresie ciąży i połogu porównano między grupami oraz do wyników uzyskanych w 1 trymestrze ciąży. Wyniki: Analiza przepływu krwi wykazała, że prędkość przepływu krwi w badanych naczyniach była statystycznie niższa w grupie z niewydolnością żylną. Zmiany prędkości przepływu w czasie wykazały, w większości przypadków, znaczne zmniejszenie prędkości przepływu krwi w trzecim trymestrze ciąży w obu grupach. W okresie połogu obserwowano wzrost prędkości przepływu krwi do wartości nieróżniących się od tych obserwowanych w pierwszym trymestrze. Tendencja zmian prędkości przepływu krwi była podobna w obu grupach. Wnioski: Zmiany układu żylnego kończyn dolnych związane z ciążą wykazały zmniejszenie prędkości przepływu krwi w zaawansowanym wieku ciążowym i były bardziej widoczne w ciąży powikłanej niewydolnością żylną

Zmiany szerokości naczyń kończyn dolnych w przebiegu ciąży powikłanej niewydolnością żylną

Aim: to analyze the changes in the width of selected veins in the lower limbs during pregnancy and puerperium, with or without venous insufficiency(VI) diagnosed at the first trimester. Material and methods: the group of 100 pregnant was divided into two subgroups with or without VI. The examination was performed, namely between 11-14th, 18-22nd, 28-32nd weeks of gestation and in 6th week of the puerperium. The sonographic examination included the measurement of the transverse diameter (TD) of the common femoral vein (CFV), the superficial femoral vein (SFV) and the popliteal vein (PV). The changes in the vessel width during pregnancy and puerperium were compared in both groups. Moreover, the changes of analyzed ultrasound parameters between the two groups in the 4 analyzed time periods were compared to the first trimester results. Results: there was a statistically significant increase in the TD of CFV with the highest values in the third trimester and significantly higher in the puerperium compared to the first visit. TD in all analyzed stages of pregnancy in the group with VI was significantly higher. SFV and PV were not statistically different between the groups in any of the analyzed periods. Average TD of these vessels was higher in the third trimester, decreasing gradually during the postpartum period. Conclusions: The average TD was highest in the third trimester, decreasing during the postpartum period. In VI group a full return of TD to the values observed in the first trimester was not observed in the puerperium.Cel: analiza zmian szerokości wybranych żył kończyn dolnych w ciąży i połogu, z lub bez niewydolności żylnej (VI) rozpoznanej w pierwszym trymestrze ciąży. Materiał i metodyka: Grupa 100 ciężarnych została podzielona na dwie podgrupy, z lub bez niewydolności żylnej. Badanie przeprowadzono pomiędzy 11-14, 18-22, 28-32 tygodniem ciąży oraz w 6 tygodniu połogu. Badanie ultrasonograficzne obejmowało pomiar wymiaru poprzecznego (TD) żyły udowej wspólnej (CFV), żyły udowej powierzchownej (SFV) i żyły podkolanowej (PV). Porównano zmiany szerokości naczyń podczas ciąży i połogu w obu grupach. Ponadto zmiany analizowanych parametrów ultrasonograficznych pomiędzy obu grupami w 4 analizowanych okresach czasu porównano do wartości w pierwszym trymestrze. Wyniki: Stwierdzono istotny statystycznie wzrost szerokości wymiaru poprzecznego CFV z najwyższymi wartościami w trzecim trymestrze. Wartości obserwowane w okresie połogu były istotnie wyższe od obserwowanych w czasie pierwszej wizyty. TD we wszystkich analizowanych okresach ciąży, w grupie VI był znacznie wyższy. SFV i PV nie różniły się statystycznie pomiędzy grupami w żadnym z analizowanych okresów. Średnia wartość TD tych naczyń była wyższa w trzecim trymestrze, zmniejszając się stopniowo w okresie poporodowym. Wnioski: Średnia wartość TD była najwyższa w trzecim trymestrze ciąży, zmniejszając się w okresie poporodowym. W grupie z VI w okresie połogu nie obserwowano pełnego powrotu wartości TD do wartości obserwowanych w pierwszym trymestrze ciąży

Management of pregnancy complicated by intrauterine fetal growth restriction

Intrauterine growth restriction (IUGR) is defined as fetal growth below the expected genetic potential. The paper presents the principles of fetal surveillance in pregnancy complicated by IUGR in accordance with the guidelines of the Fetal Medicine Foundation (FMF). Fetal surveillance includes integrated monitoring by analyzing Doppler blood flow in selected vessels, fetal heart rate, biophysical profile and amniotic fluid volume. The aim of the integrated fetal monitoring is to prolong the pregnancy, to minimize the consequences of prematurity and prevent a potentially lethal damage. The paper presents the symptoms preceding the intrauterine demise and proposes methods of determining the date of delivery according to the guidelines of FMF

Pulmonary CT angiography in the diagnosis of pulmonary embolism in pregnancy – a case report

This paper describe the case of pulmonary thromboembolism (PTE) in pregnancy diagnosed by angio CT. The clinical diagnosis of PTE in normal population is difficult. In pregnancy is even more complicated, because physiologic changes of pregnancy can mimic signs and symptoms of PTE. Our patient presented dyspnoea, breathing effort and cyanosis of the mouth at admission. In the check-up there was a distinct murmur just under the heart and tachycardia 115 bpm. The Doppler examination of the venous vessels of the lower extremities was normal. Echocardiography revealed features of right ventricular failure. Due to increased level of D-dimers and echocardiographic features of right-ventricular overload, the suspicion of pneumonic embolism was made. Therefore, in order to verify the initial diagnosis the decision of pulmonary CT angiography was made with the radiological protection of the fetus. This study revealed pulmonary embolism in the form of numerous defects in the contrast fillings of the pulmonary arteries. CT pulmonary angiography is the first imaging test of choice in general population who is suspected to have PTE. However, there is no consensus what should be preferred during pregnancy. In this paper the diagnostic concepts and an evidence-based guidelines were discussed in case of PTE in pregnancy as well as its side effects including teratogenicity and oncogenicity. In each case, the risks and benefits must be compared before a decision is taken. In case of thrombosis symptoms in the lower extremities, ultrasound should be taken as the next step, otherwise chest X-ray must be performed. In patients with normal chest X-ray, the next step should be scintigraphy, but if chest X-ray is abnormal, angio CT is preferred

Kolizja pępowinowa w I trymestrze w ciąży bliźniaczej jednoowodniowej – czy naprawdę ma znaczenie?

In the first ultrasound scan there were no abnormalities in twin I. In contrast, in twin II a vascular resistance in the umbilical artery was at the upper limit for the gestational age. Five days later, decreased vascular resistance in the middle cerebral artery, which fluctuated at the lower limit, was noticed in twin II. After the next four days, PI in the middle cerebral artery decreased below the lower limit and tricuspid regurgitation appeared. In twin I the vascular resistance in the umbilical artery increased and remained at the upper limit of the reference ranges. Cardiotocographic records did not reveal signs of fetal distress. After a week the signs of brain sparing effect were visible in both fetuses. However, twin II showed features of umbilical cord clamping in the form of abnormal blood flow waveforms in the umbilical artery („notch”). Therefore, despite the absence of signs of fetal distress in CTG in monochorionic monoamniotic twins with growth discordance of 20% and exponents of periodical clamping of the umbilical cord in twin II at 34 weeks, the decision to perform a caesarean section was made. The patient gave birth to two daughters (twin I: weight 1780g, Ap 10, pH 7.39, 7.40, BE -3.0, -2.6, and twin II: weight 1860g, Ap 10, pH 7.29, 7.35, BE -1.4, -2.4). During the delivery the umbilical cords collision was found at the region close to the body of twins. This case presents the possibility of using ultrasound and Doppler in the early diagnosis, monitoring and surveillance of pregnancies complicated by umbilical cords collision in monochorionic monoamniotic twins from the first trimester. Application of these methods allowed a safe monitoring of the fetuses and the identification of the onset of the cords collision. This in turn allowed the achievement of fetal maturity at 34 weeks, when both the risk of death and neonatal morbidity are significantly minimized. The use of Doppler blood flow velocimetry allowed the diagnosis of umbilical cords tightening before there were any signs of cardiac dysfunction in the CTG. This enabled to determine the most favorable, earlier time for delivery. The paper presents diagnostic management and surveillance in monochorionic monoamniotic pregnancy complicated by umbilical cord collision since the early pregnancy.Praca przedstawia przypadek kolizji pępowinowej zdiagnozowanej w I trymestrze ciąży bliźniaczej jednokosmówkowej jednoowodniowej. Intensywny nadzór prowadzony przy pomocy ultrasonografii wraz z opcją kolorowego, spektralnego Dopplera oraz echokardiografii umożliwiło bezpieczne monitorowanie ciąży do 34 t.c., kiedy to badania dopplerowskie wykazały objawy zagrożenia życia płodu. Zastosowanie badania dopplerowskiego umożliwiło diagnostykę zaciskania się zapętlonych sznurów pępowinowych zanim pojawiły się zaburzenia czynności serca w zapisie KTG. Umożliwiło to podjęcie decyzji o wcześniejszym zakończeniu ciąży, które odbyło się drogą cięcia cesarskiego. Praca przedstawia postępowanie diagnostyczne oraz monitorowanie ciąży jednoowodniowej powikłanej kolizjąpępowinową od wczesnego etapu ciąży

Doppler blood flow velocimetry in the umbilical artery in uncomplicated pregnancy

Objective: To determine the resistance index (RI) and pulsatility (PI) in the umbilical artery (UA) in prediction of abnormal fetal heart rate during labor and poor fetal outcome in term pregnancy. Material and Methods: The study included 148 patients at term in uncomplicated pregnancy. Daily evaluation of blood flow in the UA was performed and PI and RI were calculated. The last value before delivery was taken for the analysis. In turn predictive value of Doppler parameters has been determined in the prediction of abnormal FHR during labor and abnormal newborn condition. Evaluation included fetal CTG parameters and newborn status based on the V.Apgar scale and acid-base equilibrium in the umbilical cord blood. Then selected parameters, characterizing pregnancy and the newborn status, with abnormal Doppler results were compared. The prognostic value of Doppler indices was assessed for selected parameters determining the course of pregnancy and abnormal fetal heart rate. Results: A poor predictive value of UA PI and RI in the prediction of abnormal fetal heart rate during labor and poor fetal outcome was found. The RI in the UA presented the highest predictive value. Conclusion: RI in the UA shows higher predictive value than PI in the detection of abnormal fetal outcome and abnormal fetal heart rate in uncomplicated pregnancy at term. However, PI as well as RI in the UA have a low predictive value for the analyzed parameters

Risk factors for the development of venous insufficiency of the lower limbs during pregnancy – part 1

The venous system alters its function in pregnancy - the changes are both functional and structural. It becomes particularly vulnerable to the development of venous thrombosis and related complications. These adverse factors acting on the veins in pregnancy include: an increase in circulating blood volume, expansion of the uterus, weight gain, reduced physical activity, hormonal changes. The changes in the plasma have a significant impact on the venous system. In pregnancy, an increased level of fibrinogen and coagulation factors VII, VIII, IX and X, and von Willenbrand factor, can be observed. Smooth muscle relaxation and relaxation of collagen fibers are caused by progesterone and estrogen, and it may result in the development of varicose veins, venous thrombosis and venous insufficiency. The relationships between the hormones and the muscle pump efficiency has not been proven as yet. Estrogens cause an increase in the synthesis of coagulation proteins and it may result in the high risk of venous thrombosis and its consequences. Progesterone inhibits smooth muscle contraction, while estrogens cause relaxation and loosening of the bonds between the collagen fibers. The increase in the level of progesterone is of particular importance. It has a relaxing effect on the muscle, resulting in disorders of the vein shrinkage, affecting the increase of their capacity, and valvular insufficiency, and valvular edges are not in contact with each other due to the vasodilatation. Estrogens have a similar effect, and additionally it may also cause an impairment in the collagen fibers connection and synthesis. This can result in the formation of telangiectasia without venous hypertension. Estrogens may also affect the synthesis of prostaglandins and nitric oxide. Estradiol inhibits vascular smooth muscle cell proliferation and stimulates cell migration and secretion of matrix proteins, as well as regeneration of the damaged vessels. Estrogen inhibits the production of cytokines, adhesion molecules, and reduce platelet response, i.e. the aggregation and adhesion in the presence of monocytes. Estradiol increases the production, activity and bioavailability of nitric oxide, a molecule with a strong vasodilating effect. Additionally, adverse affects may appear due to short intervals between pregnancies, genetics, presence of venous thrombosis or venous insufficiency in the superficial and deep system in anamnesis. Caesarean section is also a risk factor for venous thrombosis. Family factors are associated with inheritance of the formation of varicose changes and venous insufficiency in both ways, dominant and recessive, and also sex-related. Among other factors affecting the development of venous insufficiency during pregnancy, the following can be distinguished: type of work (standing, sitting, in forced positions and vibration), interval between pregnancies (determining the possibility of regeneration of physiological regeneration of the system). In case of women who were pregnant more than once, the risk of developing varicose veins and other venous insufficiency is doubled

Definition, classification and diagnosis of chronic venous insufficiency – part II

Venous insufficiency can be defined as a fixed venous outflow disturbance of the limbs. It is caused by the malfunction of the venous system, that may or may not be associated with venous valvular insufficiency, and may involve the superficial or deep venous system of the lower limbs, or both. The CEAP scale includes clinical, etiologic, anatomic and pathophysiologic aspects and has been used in the assessment of venous insufficiency. Clinical classification comprises of 7 groups. It takes into account the appearance of the skin of the lower limbs, presence of edema, teleangiectasis and varicose ulcers. Clinical grading: Group C0 - no visible changes in the clinical examination; Group C1 - telangiectasis, reticular veins, redness of the skin around the ankles; Group C2 - varicose veins, Group C3 - the presence of edema without skin changes; Group C4 - lesions dependent of venous diseases (discoloration, blemishes, lipodermatosclerosis); C5 Group - skin changes described above with signs of healed venous ulcers; Group C6 - skin lesions such as in groups C1 to C4 plus active venous ulcers. Etiological classification includes: Ec – congenital defects of the venous system, Ep – primary, pathological changes of the venous system, without identification of their causes; Es - secondary causes of venous insufficiency of known etiology (post-thrombotic, post- traumatic, etc.). There are many methods of assessing the venous system. One of the most accurate methods is an ascending phlebography, which is especially useful in determining detailed anatomy of the venous system, venous patency and identification of perforans veins . The second method may be a descending phlebography, useful in determining the venous reflux and morphology of venous valves. Another radiological method is varicography, in which the injection of the contrast medium directly into the veins is performed. It is especially useful in the „mapping” of venous connections. Trans-uterine phlebography, when contrast medium is injected into the bottom of the uterus and its flow is observed, is a very rare test. A similar method is used in a selective phlebography of the ovarian vein and internal iliac vein. This examination is performed when there is a suspicion of connections between varicose veins of the inferior extremities and the pelvis, in case of the occluded iliac and femoral veins. However, these tests are highly invasive, causing a lot of discomfort and are connected with numerous complications, particularly the development of venous thromboembolism. An invasive study, but not exposing to the emission of ionizing radiation, is a measurement of the marching pressure (known also as ambulatory venous pressure - AVP). Ultrasound Doppler is the „gold standard” in the diagnosis of venous system. Color Doppler technique is irreplaceable due to its non-invasiveness, availability, constantly improving of the ultrasound machines and is the method of choice in pregnancy. Unfortunately, clinical correlation of Doppler ultrasound and thrombosis is bad. Invasive methods, which include various types of phlebographies, have been reserved only for cases of very high diagnostic doubt