Pregnancy after liver transplantation with tacrolimus immunosuppression: a single center's experience update at 13 years

BACKGROUND: Chronic liver disease often leads to amenorrhea in women of childbearing age. There are several reports of successful pregnancy after liver transplantation (LTx) with cyclosporine A immunosuppression. Tacrolimus has been increasingly used in solid-organ transplantation, and the effect of the drug on pregnancy is still of interest to clinicians. This study updates our single-center experience. METHODS: All pregnancies after LTx with tacrolimus immunosuppression were followed prospectively. Patients' clinical courses during pregnancy and labor along with gestational period and birth weight were catalogued. Changes in liver function, renal function, and immunosuppression also were recorded. The birth weight percentile was calculated on the basis of the gestational period using a standard chart. RESULTS: Thirty-seven mothers delivered 49 babies. Three mothers delivered three times, and six mothers delivered two times. Thirty-six mothers (97%) survived the pregnancy, and 36 allografts (97%) survived. The one death and graft loss was in a patient who demonstrated infra-aortic arterial graft, which clotted by the gravid uterus during labor. The patient developed a gangrenous liver and died before she could undergo retransplantation. The mean gestational period was 36.4+/-3.2 weeks, excluding two premature deliveries at 23 and 24 weeks gestation. Twenty-two babies (46.9%) were delivered by cesarean section, and the other babies were delivered vaginally. In addition to the two premature babies, one baby, who was born to a mother with Alagille syndrome, died from congenital birth defects. The rest of the newborns survived. The mean birth weight was 2,797+/-775 g, with 38 babies (78%) weighing more than 2,000 g. The mean birth weight percentile to gestational period was 54+/-23. Four babies (8.5%) had a birth weight percentile of less than 25, and 28 babies (59.6%) had a birth weight percentile greater than 50. Twelve patients demonstrated an increase in hepatic enzymes without jaundice during the pregnancy. All of them responded to augmentation of immunosuppression. CONCLUSION: The present report reconfirms the safety of tacrolimus during pregnancy after LTx. Preterm delivery and low birth weight seem to be a persistent problem in all solid-organ transplantation under any form of immunosuppression. However, toxemia of pregnancy and new onset of hypertension seem to be have a low occurrence with the use of tacrolimus.     

A study of female urinary tract infection caused by urodynamic investigation

OBJECTIVE: The purpose of this study was to assess the prevalence of female urinary tract infection before and after urodynamic investigation and to identify the risk factors for urinary tract infection after urodynamic investigation. STUDY DESIGN: Eight hundred twenty-two consecutive incontinent women were recruited. All women were "double-screened" and treated for urinary tract infection before urodynamic investigation: first by mid stream urine culture 4 to 6 weeks before investigation and then by reagent strips for urine leukocytes and nitrites at the time of investigation. The investigation was postponed until the urinary tract infection had been treated. All women then received a standard urodynamic investigation. RESULTS: The prevalence of urinary tract infection before urodynamic investigation was 5.1% (95% CI, 3.6-6.6), and the prevalence after the investigation was 8.4% (95% CI, 6.5-10.3). Three independent risk factors were identified: age >or=70 years (odds ratio, 1.99; 95% CI, 1.14-3.48), previous continence surgery (odds ratio, 1.90; 95% CI, 1.05-3.43), and urinary tract infection before urodynamic investigation (odds ratio, 3.13; 95% CI, 1.43-6.83). The 3 most common uropathogens in the urinary tract infections after the urodynamic investigation were Escherichia coli (46.3%), Enterococcus spp (16.4%), and Enterococcus faecalis (11.9%). CONCLUSION: Despite a stringent screen-and-treat protocol before urodynamic investigation, patients still experienced urinary tract infection.     

The effect of fetal behavioral states on middle cerebral artery peak systolic velocity

OBJECTIVE: This study was undertaken to determine whether is there a difference in the middle cerebral artery peak systolic velocity (MCA PSV) between active and resting behavioral states in healthy fetuses aged 30 to 32 weeks. METHODS: MCA blood flow was measured by pulsed Doppler sonography 3 times during each fetal behavioral state (active and resting). The average during active state was compared during the resting state. Statistical analysis was performed by paired t test. RESULTS: During the fetal active state, there was a significant increase in the mean PSV (51.59 cm/s vs 46.95 cm/s, P < .0001) and mean end-diastolic velocity (9.59 cm/s vs 7.98 cm/s, P=.0015), and a significant decrease in the mean pulsatility index (PI) (2.07 vs 2.19, P=.0226) and the mean resistance index (0.83 vs 0.85, P=.0481). CONCLUSION: Healthy preterm fetuses have a significantly higher MCA PSV during the active state. Activity state should be considered when interpreting MCA Doppler indices.     

Antenatal diagnosis of intrauterine infection with coxsackievirus B3 associated with live birth

BACKGROUND: Prior reported cases of stillbirth and neonates infected with enteroviruses suggest transplacental infection. We present a case of fetal infection with coxsackievirus B3, diagnosed antenatally and resulting in live birth. CASE: A pregnant woman presented at 26 weeks with fetal tachycardia and non-immune hydrops fetalis. Coxsackievirus B3 was cultured from amniotic fluid. Maternal antibody to coxsackievirus B3 was positive at 1:512. At 32 weeks, the fetus deteriorated and was delivered. Cord blood antibody to coxsackievirus B3 was positive at a higher titer. Following neonatal death, brain and placental tissues were positive for enterovirus ribonucleic acid by polymerase chain reaction. CONCLUSION: Intrauterine infection by enteroviruses should be considered in the differential diagnosis of non-immune hydrops fetalis. Antenatal diagnosis of coxsackievirus B3 infection is associated with poor outcome.     

Pregnancy after kidney and kidney-pancreas transplantation under tacrolimus: a single center's experience

BACKGROUND: Chronic renal failure leads to amenorrhea, and successful pregnancy is rare. The aim of the present report is to examine the outcome of pregnancies under tacrolimus after kidney transplantation (KTx) and simultaneous kidney-pancreas transplantation (SPKTx). METHOD: All pregnancies under tacrolimus after KTx or SPKTx from 1993 to April 2002 were retrospectively examined. Renal function and the mother's survival were followed until December 2002. RESULTS: Thirteen mothers after KTx delivered 19 babies, and 2 mothers after SPKTx delivered 3 babies. All mothers survived the pregnancy and retained allograft function. One mother had a stillborn baby from an unrecognized amniotic fluid leak and a small ischemic placenta. The mean gestational period was 34.4 +/- 5.1 weeks. Mean birth weight was 2373 +/- 1001 g. Birth-weight percentile to gestational period was 40 +/- 28. None of the mothers experienced rejection during the pregnancy. Three pregnancies in mothers with KTx experienced toxemia of pregnancy, and one mother with SPKTx developed pre-eclampsia during both pregnancies. Five mothers (6 deliveries, 27.3%) required caesarian section. During the follow-up period, one mother died from a cerebrovascular accident. Another five mothers returned to dialysis 55.6 +/- 32.4 months after the last delivery and 99.4+28.5 months after the last KTx. Both SPKTx mothers have maintained normal renal and pancreatic allograft function 42 and 62 months postdelivery. CONCLUSION: All mothers survived the pregnancy. One baby was stillborn. Forty-one percent of babies were either preterm or premature, and 27% of babies were delivered by caesarean section. Toxemia of pregnancy or pre-eclampsia was observed in 23% of pregnancies postKTx and SPKTx. None of the mothers experienced rejection during their pregnancy.     

Development and characterization of a wake-controlled exterior hood

A wake-controlled exterior hood was developed to overcome the negative influence of cross draft on an exterior hood and avoid the operation inconvenience caused by the enclosure of an airflow capture booth. This new type of local exterior hood used the hood suction flow to stabilize the dynamic vortex shedding that was induced when a crossflow passed over a blockage plate, and therefore formed a hydrodynamics-stabilized local isolation area for efficient removing of the contaminant. The development process was performed in a test section of an open-circuit wind tunnel. The blockage plate and the exterior hood model were placed in a wind-tunnel test section so that the crossflow could be freely supplied by the airstream of the wind tunnel. The laser light sheet flow visualization method and the laser Doppler velocimeter were employed to reveal the characteristics of the flow field. Primary influential parameters were factored out of the measured velocity results so that a design procedure was proposed. Experiments using hot-wire type alcohol sensors to measure the toluene vapor concentration distributions showed that the capture efficiency of this type of actively controlled hood was remarkably higher than that of an uncontrolled hood.     

Bacteremia due to Clostridium hathewayi in a patient with acute appendicitis

Clostridium hathewayi is a newly described Clostridium species isolated from the feces of healthy human individuals, but its clinical significance is not known. We describe a case of human infection associated with C. hathewayi. The bacterium (strain HKU18) was isolated from the blood culture of a 39-year-old patient with acute gangrenous appendicitis complicated by septic shock. The cells were strictly anaerobic, nonmotile rods that stained gram negative. Conventional phenotypic tests and commercial identification systems failed to identify HKU18 to the species level. 16S rRNA gene analysis showed 1.4% nucleotide difference between the sequence of HKU18 and that of C. hathewayi, indicating that HKU18 was a strain of C. hathewayi. The patient responded to appendectomy and antibiotic treatment. 16S rRNA gene sequencing would be useful in further characterizing the clinical disease spectrum of C. hathewayi.     

The unique inhibitory potentials in motoneurons that occur during active sleep are comprised of minimal unitary potentials

Loss of muscle tone during active (rapid-eye-movement, REM) sleep is due to the inhibition of motoneurons. This inhibition is manifest in high-gain intracellular electrophysiological records as hyperpolarizing synaptic noise, which includes large amplitude active sleep-specific inhibitory postsynaptic potentials (IPSPs). We report here evidence that the large active sleep-specific IPSPs are comprised of a small number of minimal unitary potentials that are characterized by fast rise-times (10-90% rise-times < or = 0.75 ms); they are present in high-gain records during quiet sleep or during active sleep where they are intermingled with larger active sleep-specific IPSPs with 10-90% rise-times > or = 1.00 ms and amplitudes that are integer multiples of the minimal unitary potentials. In hypoglossal motoneurons, the amplitude of these minimal unitary potentials averaged 0.33 +/- 0.04 mV (mean +/- S.D., n = 6). It is concluded that the large IPSPs with slow rise-times that are observed in motoneurons during active sleep are due to the nearly simultaneous arrival of multiple (< or = 5) minimal unitary potentials. We hypothesize that the same inhibitory interneurons that produce small IPSPs with fast rise-times during quiet sleep are also responsible for the large amplitude active sleep-specific IPSPs.     

Arteriovenous malformations presenting with papilloedema

Cerebral arteriovenous malformations (AVMs) are fairly common and the majority of paediatric patients with this condition also present with intracranial haemorrhage. Two patients who had an incidental finding of an AVM associated with papilloedema are described here. The first was a 13-year-old male who presented after an accidental kick to the eyes. Examination revealed bilateral papilloedema. He gave a 2-year history of intermittent headache. Brain magnetic resonance imaging (MRI) showed an unruptured AVM in the temporal lobe. Lumbar puncture revealed elevated cerebrospinal fluid pressure. Visual acuity and visual fields were normal. He was treated with acetazolamide and improved within a few weeks. He subsequently underwent stereotactic radiosurgery to the AVM. He discontinued acetazolamide due to adverse side effects and there was no recurrence of headache and papilloedema. The second patient was a 14-year-old male who had polyarticular juvenile chronic arthritis and received low-dose steroids and methotrexate. Bilateral papilloedema was discovered during routine ophthalmology surveillance and he was otherwise asymptomatic neurologically. Brain MRI revealed an AVM in the posterior fossa. He had three embolization procedures, which have resulted in significant reduction in lesion size. The papilloedema resolved completely after the first two procedures, and visual acuity and fields remained normal. Here, possible underlying mechanism of raised intracranial pressure and importance of visual assessment in those with AVMs and their management are discussed.     

Prediction of breast cancer size by ultrasound, mammography and core biopsy

Neoadjuvant chemotherapy and non-surgical tumor ablation rely upon imaging studies to determine tumor size. In this study the accuracy of ultrasound (US) mammography and core biopsy in determining tumor size was examined in 202 patients with Stages I and II breast cancer. The most accurate single modality for determining tumor size was mammography with a correlation coefficient of 0.66, followed by US (r = 0.48) and core biopsy (r = 0.28). Size measurements were less accurate in lobular than ductal cancers. The combination of the three modalities understaged 25% of the tumors > 1cm in size, and overstaged 10% of those < 1cm. The inability to accurately determine tumor size has important implications for the use of non-surgical ablation.