血浆置换联合连续静脉-静脉血液滤过在产科多器官功能障碍综合征中的应用

目的:探讨血浆置换(PE)联合连续静脉-静脉血液滤过(CVVH)的血液净化疗法在产科多器官功能障碍综合征(MODS)抢救过程中的价值.方法:8例产科MODS患者在常规治疗基础上行PE联合CVVH治疗,比较治疗前后白陶土部分凝血活酶时间(APTT)、血小板(PLT)、血肌酐(Cr)、总胆红素(TBIL)、丙氨酸转移酶(ALT)和谷草转氨酶(AST)、氧合指数(PaO2/FiO2)、血白细胞(WBC)、中心静脉压(CVP)的变化.根据A-PACHE-Ⅱ评分计算出可能死亡率,并与实际死亡率对比.结果:8例患者中6例痊愈,2例死亡.患者的可能死亡率(73.6％)显著高于实际死亡率(25.0％).联合治疗后APTT[(48.3±21.2)s]显著缩短,CVP[(8.0±2.1)cm H2O]、TBIL[(66.0±56.4) μmol/L]、血Cr[(111.0±84.5) μmol/L]、血白细胞[(16.8±5.6)×109/L]均明显下降,PLT计数[(142.2±115.0) ×109/L]、PaO2/FiO2[(342±76.3) mmHg]均明显升高(P均＜0.05).结论:PE联合CVVH治疗可显著改善产科MODS患者的临床症状,有效改善脏器功能.     

盆腔静脉瘀血症患者瘀血静脉超微结构观察

为探讨盆腔静脉瘀血症患者瘀血静脉形态学改变,本文对11例瘀血症患者和6例结扎术后无任何症状和体征的妇女盆腔静脉进行了扫描及透射电镜观察.发现瘀血静脉壁间渗出增多;内皮细胞数量增多、体积变小且外形肿胀;细胞表面粗糙,突起增粗,小孔及凹陷增多、变大;细胞质致密并含大量饮液泡,线粒体肿胀而数量增多;染色质呈块状分布于核的周边;内皮细胞间嵌合连接和紧密连接正常存在.这些变化说明缺氧是引起本症盆腔静脉超微结构改变的主要原因,提示本症是一种功能性疾病.     

13例胎儿脐-门-体静脉分流与结局之间的关系

目的 探讨胎儿脐-门-体静脉分流(umbilical-portal-systemic venous shunts, UPSVS)与预后之间的关系。方法 回顾性分析13例UPSVS的超声特点并追踪随访至出生后。结果 我们共发现4例静脉导管-体静脉分流(ductus venosus-systemic shunt, DVSS),1例肝外门静脉-体静脉分流(extrahepatic portal-systemic shunt,EHPSS),2例脐-体静脉分流(umbilical-systemic shunt, USS),其中1例同时合并肝内门静脉-体静脉分流(intrahepatic portal-systemic shunt, IHPSS),7例肝内门静脉-体静脉分流(intrahepatic portal-systemic shunt, IHPSS),发现合并染色体异常7.7%(1/13),其他超声异常46%(6/13),心胸比增大46%(6/13),胎儿生长受限38.4%(5/13),水肿7.7%(1/13),活产77%(10/13)。结论IHPSS的发生率最高,预后也相对最好,DVSS...     

浅谈静脉输液反应

掌握静脉输液过程中不良反应,采取防治措施。方法：严格执行无菌技术操作和＂三查七对＂一＂注意＂制度,多巡视、及时处置。     

产前超声诊断胎儿脐静脉-门静脉系统发育异常2例

正1病例简介病例1,女,28岁,孕28周。于我院行常规产科超声显示:单胎,双顶径70mm,头围252mm,腹围233mm,股骨50mm,羊水深度6.1cm,脐动脉S/D:3.1。胎儿上腹部斜横切面及近矢状切面均未探及门静脉窦与膈下前庭之间的静脉导管结构,矢状切面显示脐静脉入肝后经宽大的旁路流入下腔静脉,汇入处距右房约3.2cm,汇入部位以上上腔静脉明显     

剖宫产术与静脉空气栓塞

剖宫产术中静脉空气栓塞的发生率为11％～52％。虽大部分为亚临床型,但也有发生危及生命空气栓塞的可能。其发生可能与患者体位、麻醉方式,术中牵拉子宫和使子宫外置等有关。突然出现的低血压,低氧血症及终末CO_2浓度降低是静脉空气栓塞的典型临床症状。发生空气栓塞时应使患者取轻度头高位并左倾15°,用生理盐水淹没手术野,吸氧,输注乳酸林格氏液,加用血管活性药物,心肺复苏等,对高危者术时行心前区多普勒监护及放置多孔中心静脉导管。     

静脉输液技术与安全

静脉输液是临床上常用的治疗手段之一,是一种最频繁的无菌操作,同时也为细菌进入静脉提供了直接通道,具有潜在的感染及并发症危险。因此,要保证输液安全,必须树立一个理念即-输液不仅仅是一项操作,而是一个程序(评估、计划、实施、评价)。本人经过30多年的临床护理工作经验对静脉输液技术与安全有如下体会。     

胎儿脐静脉-门静脉系统发育异常产前超声诊断的研究进展

胎儿脐静脉-门静脉系统的胚胎发育过程复杂,国内外相关发育异常分类繁多。近年研究认为,脐静脉、门静脉和静脉导管为一个整体的解剖功能单元,序贯性的解剖关系是其功能的基础,任何一部分发育异常可引起其他单元部位的异常。孕期发现脐静脉-门静脉系统发育异常的胎儿,应当对整个系统进行扫查,密切关注其转归。     

静脉多普勒流速曲线与胎儿循环的研究

以往在对胎儿循环的研究中,只有动脉多普勒流速曲线.近几年静脉多普勒流速曲线的研究逐渐成为重点和热点.胎儿心脏后负荷、心肌顺应性、血容量及心率改变可以调节静脉和动脉的血流速度波形.心血管因素的改变常见于严重的胎儿生长受限、双胎输血综合征、胎儿水肿等.阐述上述胎儿病理情况下静脉导管、下腔静脉、脐静脉等的多普勒流速曲线的变化.静脉多普勒评估可提供关键性的诊断及预后信息,并对指导临床治疗起重要作用.故而全面的多普勒评估应包括静脉多普勒评估.     

Prenatal diagnosis of congenital cytomegalovirus infection

OBJECTIVE: To assess prospectively the diagnostic reliability and prognostic significance of prenatal diagnosis of cytomegalovirus (CMV) infection. METHODS: One hundred ten pregnant women (four with twin pregnancies) with a risk of congenital CMV infection were investigated. Prenatal diagnosis was carried out by amniocentesis and fetal blood sampling (n = 75) or amniocentesis alone (n = 35). Serial ultrasonographic examinations were performed from time of referral until pregnancy end. All infected neonates were given long-term follow-up. Autopsy was performed in all cases of termination of pregnancy. RESULTS: Nearly 23% (26 of 114) of fetuses were infected and prenatal diagnosis was positive in 20 cases. Sensitivity of prenatal diagnosis was 77% and specificity 100%. In eight cases, parents requested termination of pregnancy on the basis of abnormal ultrasonographic findings and/or biologic abnormalities in fetal blood. In 12 cases, parents decided to proceed with the pregnancy. In this group, one intrauterine and one neonatal death were observed. In one case, prenatal diagnosis revealed an abnormal cerebral sonography and the infant had bilateral hearing loss at birth. In 15 cases (nine positive and six false-negative prenatal diagnoses), no apparent lesion was present at birth, nor did it develop during the follow-up period (mean 31 months). In 88 (77.2%) of 114 infants, no evidence of vertical transmission was found during the pre- or postnatal period. CONCLUSION: Prenatal diagnosis provides the optimal means for both diagnosing fetal infection (amniocentesis) and identifying fetuses at risk of severe sequelae (ultrasound examination, fetal blood sampling), thus allowing proper counseling.     

Prenatal diagnosis and management of mild fetal pyelectasis: implications for neonatal outcome and follow-up

OBJECTIVES: To describe the natural history of pyelectasis from its detection in the second trimester to delivery, its capability to predict renal pathology and whether prenatal development of pelvic dilatation is correlated to its postnatal evolution. STUDY DESIGN: A retrospective analysis involving 375 fetuses with a complete urological follow-up. Prenatal ultrasound was correlated with the results of postnatal investigation and frequency of postnatal surgery was established. RESULTS: Two-hundred and eighty cases underwent at least two examinations before birth. 73.1% were male fetuses. 57.4% had a bilateral pyelectasis. Prenatal evolution of pelvic dilatation was the following:18.6% of the cases normalized, in 34.6% of the cases the dilatation reduced but did not disappear, in 30.7% it remained unchanged, while it worsened in 16.4%. One case from the first group, three cases from the second, seven cases from the third and 11 cases from the fourth needed surgical treatment. 1.9, 7.2, 18.6, 23.9% of cases respectively worsened after birth in the four groups (trend: P=0.001). CONCLUSIONS: Prenatal diagnosis of pyelectasis improves the outcome of these children due to a surgical approach that avoids renal damage. There is a good correlation between prenatal evolution and postnatal outcome, although a postnatal follow-up is opportune in those cases that normalized before birth.     

Meconium peritonitis: prenatal diagnosis, postnatal management and outcome

OBJECTIVES: Prenatal ultrasonography (USS) is a routine screening test for fetal abnormalities. Its accuracy for detecting meconium peritonitis (MP), which may carry high mortality, is important for prenatal counseling. The aim of this study was to assess the accuracy of prenatal USS for diagnosing MP and predicting patient outcomes. METHODS: The prenatal and postnatal medical records of all patients referred to our institutions with confirmed MP were reviewed, with emphasis on prenatal USS findings, results of postnatal investigations, operative findings, outcomes, and possible causes of MP. RESULTS: From January 2000 to November 2004, seven fetuses were confirmed to have MP at birth. Three MP patients (3/7, 43%) were diagnosed prenatally because of USS showing ascites and calcification/dilated or hyperechoic bowel loops. One (1/7, 14.3%) suspected cystic MP was confirmed by prenatal MRI. In the other three cases, USS showed only ascites. All patients had postnatal contrast CT scans. Two patients' CT scans showed persistent intestinal perforation not visible with prenatal USS, and required emergency operations. All patients survived and prospered, and were sweat test negative. CONCLUSIONS: Prenatal USS allows suspected MP babies to be transferred to a tertiary centre for delivery and appropriate management. In this way, the chances of survival of these babies can be excellent if they are not associated with cystic fibrosis (CF). Prenatal MRI can improve the low diagnostic yield of prenatal USS for MP. Postnatal contrast CT scan is required to define persistent intestinal perforation invisible with prenatal USS.     

The role of ultrasonography in the diagnosis of fetal isolated complete agenesis of the corpus callosum: a long-term prospective study

Objective.?To evaluate the role of a dedicated neurosonographer in prenatal diagnosis of isolated complete agenesis of the corpus callosum (iCACC) and to asses the postnatal outcome of these infants.

Methods.?Prospective study between January 2004 to December 2004 at Fetal Maternal Medical Centre ‘Artemisia’, Rome, Italy. A detailed ultrasound scan was performed in fetuses affected by iCACC by a dedicated fetal neurosonographer (CG). In all cases, magnetic resonance imaging (MRI) within 5 weeks and 13–15 months after birth was performed. A comparison was made between prenatal findings following the ultrasound scan and postnatal MRI. In these cases, a follow-up of 4-years was performed with a neurological evaluation.

Results.?Among 23 cases of ACC diagnosed at our centre in the study period, CACC was diagnosed in 17 fetuses. Two were then excluded due to associated malformations, one was lost at follow-up and one patient opted to terminate her pregnancy. Newborn MRI confirmed the ultrasonographic diagnosis of iCACC in all 13 cases. A regular development was present in 92.3% of prenatally diagnosed iCACC.

Conclusion.?A dedicated neurosonographer could diagnose the iCACC with the same accuracy as MRI and in up to 90% of cases the newborn will have a regular development.     

Congenital hydronephrosis: correlation of fetal ultrasonographic findings with infant outcome

Although congenital hydronephrosis is a common fetal disorder, ultrasonographic criteria for prenatal diagnosis remain poorly defined. In this study prenatal ultrasonographic findings were correlated with postnatal outcome in 63 fetuses with suspected hydronephrosis. Prenatal ultrasonographic measurements included length, anteroposterior diameter, and transverse diameter of the kidney and renal pelvis, as well as dorsal renal parenchymal thickness. In 45 of the 63 fetuses, hydronephrosis was confirmed postnatally. These infants were divided into two groups on the basis of renal status: (1) abnormal renal function and/or surgery required (n = 31) and (2) normal renal function with no surgery required (n = 14). The anteroposterior diameter of the renal pelvis was the simplest and most sensitive technique for prenatal diagnosis of congenital hydronephrosis, allowing identification of 100% of cases. Postnatal follow-up studies are warranted if an anteroposterior pelvic diameter is greater than or equal to 4 mm before 33 weeks or greater than or equal to 7 mm after 33 weeks.     

Fetal intra-abdominal calcifications from meconium peritonitis: sonographic predictors of postnatal surgery

OBJECTIVE: To study the relationship between prenatal ultrasound features and postnatal course of meconium peritonitis. STUDY DESIGN: We reviewed our cohort of cases of meconium peritonitis (MP) (n = 13/37, 225 pregnancies or 0.3/1000) as well as those published in the English literature with prenatal ultrasonographic findings and postnatal follow-up (n = 56). The total number of cases (n = 69) was divided into 4 grades of progressive severity based on the number of pertinent sonographic findings: grade 0, isolated intra-abdominal calcifications (n = 18); grade 1, intra-abdominal calcifications and ascites (n = 17) or pseudocyst (n = 2) or bowel dilatation (n = 6); grade 2, two associated findings (n = 20); and grade 3, all sonographic features (n = 6). Presence of polyhydramnios was also recorded. Prenatal predictors of need for neonatal surgery and risk of neonatal death were identified using Chi-square and Fisher exact test, with P < 0.05 considered significant. RESULTS: Neonatal surgical intervention was required in 0% (0/18) of newborns with grade 0 MP; in 52% (13/25) of those with grade 1; in 80% (16/20) with grade 2; and in 100% (6/6) with grade 3 MP (P < 0.001, Chi-square for trend). Moreover, neonatal surgery was more frequent in the presence than absence of polyhydramnios [69% (18/26) vs 37% (16/43); P = 0.007]. Neonatal mortality was 6% (4/69; 3 after surgery and 1 for premature delivery) and it was confined to the subgroup with polyhydramnios (4/26, 15%). CONCLUSIONS: Prenatal sonographic features are related to postnatal outcome. Persistently isolated intra-abdominal calcifications have an excellent outcome. Delivery in a tertiary care center is recommended when calcifications are associated with other sonographic findings.     

The specificity of ultrasound in the detection of fetal intracranial tumors

AIMS: To evaluate the specificity of ultrasound in identifying fetal brain neoplasms and its accuracy in the diagnosis of the tumor's histological type. METHODS: A retrospective evaluation of 7 cases of fetal brain tumors occurred at our unit in the period between January 92 and June 98 has been performed. All prenatal ultrasonographic diagnoses were compared with the postnatal findings on the aborted fetuses (post-mortem examination) or on the newborns (MRI or post-mortem examination). RESULTS: In 6 out of 7 cases the antenatal ultrasonographic diagnosis of brain tumor was confirmed postnatally, in one case a supratentorial arachnoid cyst was mistaken for a teratoma with cystic components (86% specificity in the diagnosis of congenital brain neoplasms). Out of the 6 cases of suspected teratomas, one revealed to be a glioblastoma, one an arachnoid cyst and one a primitive neuroectodermal tumor. The prenatal diagnosis was confirmed in the case of choroid plexus papilloma. Prenatal ultrasonography was accurate in identifying the tumor's histological type in the 57% of the cases. The diagnoses were not modified by the transvaginal scans performed in 2 cases. CONCLUSIONS: Prenatal ultrasonography is a useful tool to identify any intracranial space-occupying lesion larger than 10 mm. In the present study it has shown an 86% specificity in the diagnosis of brain neoplasms. However the accuracy of ultrasound in diagnosing the tumor's histological type was limited (57%).     

Chromosomal anomalies and additional sonographic findings in fetuses with open neural tube defects

Objective

To evaluate the results and the necessity of chromosome analysis in fetuses prenatally detected with a neural tube defect and to determine the significance of ultrasonographic evaluation for the identification of underlying or accompanying chromosomal anomalies.

Methods

Ninety fetuses that underwent prenatal and/or postnatal chromosome analysis after being diagnosed with open neural tube defects (NTD) between the years 2006 and 2010 in the Department of Obstetrics and Gynecology at Ondokuz Mayis University School of Medicine were included in this study. Detailed fetal ultrasonography was performed in all cases in order to investigate any additional anomalies. Karyotype was determined in the prenatal period by amniocentesis in 72 (80?%) of the 90 fetuses, and by cordocentesis in 5 (5.5?%). In 13 (13.3?%) fetuses, karyotype was determined in the postnatal period by blood sampling.

Results

Fourteen (15.5?%) of the 90 fetuses were diagnosed with acrania/anencephaly, 14 (15.5?%) with encephalocele, 2 (2.2?%) with iniencephaly, 60 (66.6?%) with open spina bifida. None of the 90 fetuses with open NTD who had undergone chromosome analysis was diagnosed with chromosomal anomalies. None of the 19 (21.1?%) fetuses diagnosed with additional ultrasound findings had a chromosomal abnormality, either. Seventy-one (78.9?%) fetuses having sonograhically isolated NTD were also isolated in postmortem examination.

Conclusion

In fetuses with open NTD, we could not find the chromosomal anomaly rate as high as reported in previous literature. The necessity of fetal karyotyping should be questioned especially in isolated cases.     

Prenatal diagnosis of suprarenal mass by magnetic resonance imaging: a case series

Objective: The aim of this study was to evaluate the perinatal outcomes and postnatal follow-up of prenatally diagnosed suprarenal masses (SRMs) evaluated by magnetic resonance imaging (MRI).

Methods: Thirteen fetuses with SRMs detected during routine prenatal ultrasound screening were evaluated by MRI between February 2007 and May 2015. The prenatal characteristics of the masses, complications of the pregnancies, and related malformations were collected as the postnatal clinical, radiological, and pathological data.

Results: The median gestational age at MRI was 30 weeks (18–41), and birth weight was 3285 (1700–3750) g. The mean follow-up period was 6 years (1.3–10). We observed 69.2% of the masses, which were predominantly cystic (69.2%), located on the left side. Associated malformations were found in 23% of the fetuses, with congenital heart defects being more prevalent. During the pregnancy, 15.4% of the fetuses had involution of the SRM, and one fetus had surgical treatment and different ultrasound and MRI diagnoses. Of the 69.2% of the cases, spontaneous resolution occurred in 30.7% during the first year of life and 38.4% the masses presented without modifications or signs of regression since the neonatal period.

Conclusions: Prenatal SRMs were associated with congenital heart defects. Spontaneous regression and absence of modifications in the masses were commonly observed in the long-term follow-up of the SRMs.     

Fetal hydronephrosis: does adding an extra parameter improve detection of neonatal uropathies?

Objective: The aim of this study is to assess the correlation of the average antero-posterior, transverse and longitudinal diameters of the fetal renal pelvis to neonatal outcome. Methods: This retrospective study evaluates the neonatal outcome of all fetuses with suspected pyelectasis on ultrasonographic examination between May 1997 and March 2006. During this time, 764 fetuses with pyelectasis and 1285 renal units were scanned. We defined fetal pyelectasis as mild if the ARP was ≥5–<10?mm, moderate if ARP ≥10–<15?mm and severe if ARP ≥15?mm. A total of 612 fetuses met the inclusion criteria. The Corteville criteria in the third trimester (antero-posterior diameter ≥7?mm) and an antero-posterior diameter (AP) of ≥10?mm were compared with the ARP and likelihood ratio’s calculated. Ultrasonographic evaluation took place in the third trimester if fetal pyelectasis was diagnosed as an isolated finding in the second trimester. This last ultrasonographic examination was used for final analysis and as a guideline for postnatal follow-up. Neonatal outcome was assessed by reviewing medical records, ultrasonographic, renographic and voiding cysto-urethrographic results. Results: Of all the fetuses diagnosed with renal pelvis dilatation in the third trimester of pregnancy, 73 (11.9%) infants needed postnatal surgery. The majority of the postnatal surgery was performed in the group of fetuses with severe hydronephrosis (8.2%). This resulted in a LR of 5.81 and a post-test probability of 61.3%. In total, 78.8% of the fetuses with hydronephrosis had spontaneous resolution across all grades of severity on the first postnatal ultrasonogaphic investigation or during their follow-up. In 9.3% of the cases, uropathies were diagnosed, but no surgical intervention had taken place during the follow-up period. Using the Corteville criteria as gold standard for the third trimester (AP ≥7?mm), 11 (1.8%) patients would not have been diagnosed with uropathies. And in the case of AP ≥10?mm, 5.1% of the cases would have been missed. Conclusion: An ARP of ≥5?mm in the second and/or third trimester of pregnancy enables a better detection of patients with uropathies and indication for surgery as compared with AP ≥10?mm, but renders almost similar results compared with the Cortville criteria (AP ≥7?mm) in the third trimester.