Non-complicated Pregnancy Research Articles

O32. Pre-eclampsia and thrombophilia: Prevention issues

Evaluation of effectiveness of prophylaxis treatment to prevent recurrent PE in patients with thrombophilia. Control group – 105 women with noncomplicated pregnancy (noncomplicated obstetrics, thrombotic and family anamnesis). DIC-syndrome markers: D-dimer, OAO, prothrombin time, prothrombin fragments F1+2, level of fibrinogen, AT III. Detection of aggregation of platelets. Detection of homocystein level. Detection global function of protein C. Detection of antiphospholipid antibodies circulation. Gene tests: FV Leiden, prothrombin G20210A, PAI-1 G4/G5 polymorphism, t-PA “I/D” polymorphism, gene MTHFR C677T, platelets glycoproteins polymorphism: GP IIb/IIIa, GP Ia/IIa, GPIba, GP ADP. The outcomes of pregnancy in this group of the patients were the following: fetal growth retardation syndrome was noted in 18 patients out of the group, in 6 patients from the subgroup I and in 12 patients from subgroup II. The premature delivery was not observed in any patients in subgroup I, in subgroup II it was observed in 5 and no patients in control group had premature delivery. We were able to prevent severe PE, but moderate PE was in 5 patients from II subgroup. Preventive therapy of the patients include: LMWH (Enoxaparin 20–60 mg), micronized progesterone, antioxidants (Vitrum® Cardio Omega 3), vitamin B (Multi- tabs B-complex), folic acid (folacin) since fertile cycle, aspirin (except the I trimester of pregnancy and lactation). All the patients delivered via cesarean section. In the control group only 24 (22,8%) patients delivered via cesarean section, mostly elective one: due to high degree of myopia, scar on the uterus after the cesarean section surgery, pelvic presentation of fetus. 158 live children were born, with mean weight 3250 ± 250 g, height 51 ± 2 cm, Apgar score 71%- 8–9 points and 29%- 7–8 points. Early neonatal period was unremarkable. The most effective prophylaxis of recurrent severe PE- preventive therapy since fertile cycle, which must include LMWH, micronized progesterone, folic acid, group B vitamins and antioxidants.

Origin and levels of circulating microparticles in normal pregnancy: A longitudinal observation in healthy women

Objective. Microparticles (MP) are actively involved in the hypercoagulable state reported both in normal pregnancies and in pregnancy diagnosed with placenta-mediated complications. In this study the origin and the levels of plasma MP as well as MP activity were evaluated in a group of healthy women during the three trimesters of a normal pregnancy. Materials and methods. Seventy-five healthy normotensive pregnant women were enrolled and blood samples were prospectively collected at three different time points corresponding to 1st trimester, 2nd trimester, 3rd trimester of pregnancy. A group of age- matched healthy non-pregnant women acted as controls. Both standard clotting parameters and MP of different origin were measured. MP were identified by size and annexin V- FITC labelling using flow-cytometer. MP subtypes were identified using specific monoclonal antibodies. Procoagulant activity of MP was assessed using the STA® Procoag PPL assay. Results. The levels of total, platelet-, endothelial-, leukocyte-derived and tissue factor-bearing MP, as well as the MP procoagulant activity, in non-complicated pregnancy were higher in the 1st trimester as compared to non-pregnant age-matched women. Regardless of the origin, MP levels gradually increase during pregnancy, with the highest values reached in the 3rd trimester. Conclusions. MP levels gradually increase during normotensive pregnancy. All types of MP including TF+ present with the highest levels in the 3rd trimester. MP convey prothrombotic and proinflammatory antigens already from the first trimester of normal pregnancy. This may contribute to the global hypercoagulable state observed, particularly in the last months of pregnancy, also in healthy women.

Vascular endothelial growth factor role in predicting vascular disorders in pregnant with fetal growth restriction syndrome

The review covers the up-to-date data of vascular endothelial growth factor role in forming of placental blood circulation in non-complicated pregnancy and in fetal growth retardation syndrome. It is shown that the normal trophoblast invasion to the spiral arteries wall in the myometrium and adequate remodeling of spiral arteries are essential for the normal fetal growth and development. The processes of blood vessels formation - vasculogenesis and angiogenesis - are described in detail. The process of angiogenesis regulation by growth factors and their receptors is reviewed. The importance of angiogenic and antiangiogenic factors coordinated action for the adequate placental microvasculature formation and normal fetal development is described. The growth factor complexes and their receptors formation processes and competition for receptor binding, as well as the role of placental growth factor in uteroplacental complex angiogenesis are analyzed. It is shown that the serum growth factors represent the mechanisms of pathologic reactions in placental insufficiency and fetal growth restriction syndrome. Special attention is given to the family of vascular endothelial growth factor as for the most important angiogenesis regulator. To determine the physiological role of vascular endothelial growth factor and to assess the its influence on angiogenesis and adequate uteroplacental and fetoplacental blood circulation formation, the features of vascular endothelial growth factor chemical structure are described. Determining the vascular endothelial growth factor in blood may be used to assess the mother-placenta-fetus system formation. The need for developing the criteria for choosing the optimal delivery term in pregnant with fetal growth restriction syndrome is discussed.

ТЯЖЕЛАЯ ЭПИЛЕПТИЧЕСКАЯ ЭНЦЕФАЛОПАТИЯ РАННЕГО ДЕТСКОГО ВОЗРАСТА, АССОЦИИРОВАННАЯ С МУТАЦИЕЙ В ГЕНЕ SCN2A

SCN2A mutations are traditionally described in benign infantile seizures. We are describing rather rare case of epileptic encephalopathy associated with incertion of ctg/ctGg in SCN2A. The female child was born at term by normal delivery after non-complicated pregnancy. Seizures started when she was 3 months old as focal tonic, later on myoclonic seizures developed. They were refractory to all used antiepileptic drugs including valproic acid, topiramate, lamotrigine, ethosuximide and tetracoside. At age of two child is mentally retarded and autistic, unable to walk (because of muscular hypotonia), has no active speech and still has asymmetrical tonic and myoclonic seizures. Unspecific modest brain atrophy was revealed by MRI. Metabolic screening, including urine and serum amino acids, organic acids, lactate, was normal. Our case (alongside with others depicted in literature) confirms that spectrum of phenotypes, associated with mutations in SCN2A, is very wide – from benign infantile seizures to severe epileptic encephalopaties leading to mental retardation, motor and speech disorders.

Clinical Implications

HomeHypertensionVol. 63, No. 6Clinical Implications Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBClinical Implications Originally published1 Jun 2014https://doi.org/10.1161/HYPERTENSIONAHA.114.03613Hypertension. 2014;63:1137Eligibility for Renal Denervation (page 1319)Based on the SYMPLICITY studies and Conformité Européenne certification, renal denervation is currently applied as a novel treatment of resistant hypertension in Europe. However, information on the proportion of patients with resistant hypertension qualifying for renal denervation after a thorough workup and treatment adjustment remains scarce. This issue of Hypertension includes a study that aimed to investigate the proportion of patients eligible for renal denervation and the reasons for noneligibility at 11 expert centers participating in the European Network COordinating Research on renal Denervation in treatment-resistant hypertension (ENCOReD). The analysis included 731 patients. After careful screening and treatment adjustment at hypertension expert centers, only ≈40% of patients referred for renal denervation, mostly by specialists, were eligible for the procedure. The main reasons of noneligibility were normalization of blood pressure after treatment adjustment (46.9%), unsuitable renal arterial anatomy (17.0%), and previously undetected secondary causes of hypertension (11.1%). Our findings highlight that hypertension centers with a record in clinical experience and research should remain the gatekeepers before renal denervation is considered. Moreover, assuming that renal denervation would be efficacious in a large number of patients with a variety of conditions may be overly optimistic. This groundless belief might well explain why SYMPLICITY HTN-3 failed to reach its primary end point for efficacy.Download figureDownload PowerPointEstrogen Receptor-β and Intracranial Aneurysm Rupture (page 1339)Clinical observations suggest that postmenopausal women have a higher incidence of aneurysmal subarachnoid hemorrhage than premenopausal women. In addition, hormone replacement regimens that contain estrogen seem to reduce the risk for subarachnoid hemorrhage in postmenopausal women. These clinical observations led to the hypothesis that estrogen may protect against the development of intracranial aneurysm rupture (subarachnoid hemorrhage) in postmenopausal women. In this issue of Hypertension, Tada et al sought to establish the causal relationship between estrogen treatment and the prevention of aneurysmal rupture in postmenopausal mice. They used a mouse model of intracranial aneurysm. This model recapitulates the key features of human intracranial aneurysms, including spontaneous rupture. In ovariectomized female mice, estrogen significantly reduced the rupture rates. The protective effect of estrogen seemed to occur through the activation of estrogen receptor-β, a predominant subtype of estrogen receptor in human intracranial aneurysms and cerebral arteries. Estrogen’s unwanted effects are often attributed to its agonistic activity without tissue specificity. Selective estrogen receptor modulators can exert agonistic or antagonistic actions on estrogen receptor subtypes in a tissue-specific fashion. Findings from this study may become the basis for testing selective estrogen receptor modulators with a favorable tissue and receptor subtype specificity profile for the prevention of the growth and rupture of intracranial aneurysms in humans, particularly in postmenopausal women.Download figureDownload PowerPointCardiometabolic Risk at 5 Years (page 1326)The time immediately before and after birth may be a sensitive period related to programming cardiometabolic risk. The present prospective study, performed in children born at term after a noncomplicated pregnancy, shows that birth weight and postnatal weight gain exert independent influences on cardiometabolic parameters at 5 years of age. Although birth weight influenced the metabolic parameters, insulin levels, homeostatic model assessment index, and postnatal weight gain influenced both metabolic parameters and blood pressure values. Throughout the study, systolic blood pressure was related to weight gain, and at 5 years the heaviest children had the highest systolic blood pressure. Moreover, the highest values of insulin, homeostatic model assessment index, and triglycerides were related to both weight gain and current weight. Interestingly, small for gestational age children had the highest values of fasting insulin and homeostatic model assessment index and the lowest high-density lipoprotein. Therefore, it stands to reason that subjects smaller at birth who gain more weight have more risk for metabolic alterations, a fingerprint of early subtle adaptations in the glucose-insulin metabolism. Furthermore, a clustering of higher blood pressure values, insulin levels, and uric acid levels has been observed early in life, indicating the potential for increased cardiometabolic risk later on. This information provides a window of opportunity for intervention to avoid an unbalanced weight gain and to reduce the potential increment of cardiometabolic risk later in life.Download figureDownload PowerPoint Previous Back to top Next FiguresReferencesRelatedDetails June 2014Vol 63, Issue 6 Advertisement Article InformationMetrics © 2014 American Heart Association, Inc.https://doi.org/10.1161/HYPERTENSIONAHA.114.03613 Originally publishedJune 1, 2014 PDF download Advertisement

Clinical Report: CNVs (Deletions of 3p24.1, 6p12.2; 12q24.22) Detected by Array CGH in Patient with Microcephaly and Early Epileptic Encephalopathy with Infantile Spasms

Introduction: Infantile spasms (ISs) are an age-dependent epileptic seizures that are associated with mental retardation, autism, and cerebral palsy. They are part of epileptic encephalopathies such as West and Ohtahara syndromes and early myoclonic encephalopathy. There is growing evidence that ISs result from disturbances in important genetic pathways of brain development. Recent studies show that patients with ISs may have mutations in several genes including ARX, CDKL5, FOXG1, etc. as well as other candidate genes identified from pathogenic copy number variants (CNVs). Case study: The male child was born at term by normal delivery after non-complicated pregnancy. At 3 months of age infantile spasms (ISs) started alongside with deterioration of psychomotor development, affecting head control, reaching for objects and eye tracking. At time of hospitalization ISs were numerous (hundreds per day), they were combined with myoclonic seizures and episodes of motor arrest with staring. Child had axial hypotonia, lack of hand grasping and eye contact. An electodecremental event during spasms, generalized discharges of polyspykes during myoclonias and focal spikes during motor arrest were recorded. Brain MRI showed non-specific brain atrophy. Metabolic screening, including urine and serum amino acids, organic acids, lactate, pyruvate and liver function tests, was normal. Treatment with vigabatrin with doses up to 192 mg/kg/ day was ineffective and injections of synthetic analog of ACTH were started. But the child deteriorated progressively, the burst-suppresion pattern was recorded on EEG and an epileptic status developed. IV benzodiazepine and valproic acid were only partly efficacious. Refractory epileptic status was stopped by general anaesthesia. The child survived but his developmental prognosis is poor. Since the child lacked features specific for any aetiological diagnosis an array comparative genome hybridization (array CGH) was performed. It’s revealed several copy number variants (CNVs): deletion of 3p24.1 with involvement of gene EOMES that encodes the protein-regulator of neurogenesis; deletion of 6p12.2 with involvement of gene TMEM14A (inhibitor of apoptosis) and deletion of DNA of gene FBXO21, which is highly expressed in prefrontal cerebral cortex. Discussion: Epileptic encephalopathies (EE) are severe brain disorders in which the epileptic electrical discharges may contribute to progressive psychomotor dysfunction. There are single gene disorders among them (with well described phenotype) but majority of cases remained unexplained, sometimes because of the fact that clinical and EEG features of different EE are overlapping. Molecular karyotyping can help us in defining their etiology. In our patient with EE with ISs the rare combination of copy number variations (CNVs) was found. We speculate that these CNVs (including genes playing important role in brain development) may be responsible for severe epileptic encephalopathy with ISs.

The influence of maternal smoking habits before pregnancy and antioxidative supplementation during pregnancy on oxidative stress status in a non-complicated pregnancy.

As a physiological condition closely linked with increased susceptibility to oxidative stress, pregnancy can be further compromised by cigarette smoking. Inadequate nutrition and reduced intake of antioxidants can also disrupt the prooxidant/antioxidant relationship and contribute to oxidative stress. Increased oxidative stress during pregnancy may be involved in several complications of pregnancy, such as preterm labor, fetal growth restriction, preeclampsia and miscarriage. The aim of this study was to investigate the influence of maternal smoking habits before pregnancy on the parameters of oxidative stress and the antioxidative defense system, lipid profile parameters and paraoxonase-1 (PON1) activity during the third trimester of uncomplicated pregnancies. Healthy pregnant women (n = 86) were divided into non-smoking and smoking groups, and into groups taking vitamin supplements and not taking them. Oxidative damage was measured through the levels of thiobarbituric acid-reacting substances (TBARS) and plasma antioxidant status was evaluated by measuring total antioxidant capacity (TAC). TBARS concetration was significantly higher (p < 0.05) and PON1 activity was significantly lower (p < 0.05) in the smokers' group. No significant differences were found in the investigated parameters in relation to vitamin supplement intake. Habitual smoking before pregnancy is associated with increased oxidative stress. Vitamin supplementation has no effect on the oxidative stress status of healthy pregnant women.

Prostaglandins, but not sympathetic nervous system, modulate Renin/Prorrenin receptor expression during normal pregnancy and pregnancy‐induced hypertension in rats

Pregnancy is associated with blunted response to contractile agents as angiotensin II (Ang II), catecholamines and prostaglandins (PG's). In contrast, their responses are increased in pregnancy‐induced hypertension (PIH). The renin‐angiotensin system (RAS) has become more complex with new components with cardiovascular functions. Renin/Prorenin receptor (RPR) is one of these components. The aim of this work was to elucidate if sympathetic nervous system (SNS) and/or PG's modulate RPR expression in normal and pregnancy‐induced hypertensive pregnant rats. We used a subrenal aorctic coarctation (SRAC) model. Using immunoblot, RT‐PCR and immunohistochemistry, we determined RPR expression in aorta and kidney from normal and PIH animals. Similar groups were treated with Prazosine (P, 2mg/Kg), Metoprolol (M, 5 mg/Kg), Indomethacine (I, 3 mg/Kg) or Celecoxib (C, 10 mg/Kg) during the third week of pregnancy. Neither P, M nor Cox inhibitors altered blood pressure. In normal pregnancy, RPR increased its expression significantly. RPR expression during PIH decreased even lower than control levels. Adrenergic blockers did not affect RPR expression significantly. I and C, in contrast, normalized RPR expression during non‐complicated pregnancy and increased it to higher levels during PIH. These results suggest that PG's, but no SNS, modulates RPR expression. Supported by SIP‐IPN 20120122 and 20120929 grants

Propranolol as a First‐line Treatment for Diffuse Infantile Hepatic Hemangioendothelioma

Propranolol as a First‐line Treatment for Diffuse Infantile Hepatic Hemangioendothelioma

Association of the atherogenic index of plasma and oxidative stress status with weight gain during non-complicated pregnancy

Pregnancy is a stressful condition linked with altered lipid profile, increased oxidative stress and increased inflammation processes. The purpose of the present study was to determine the associations between those alterations with increased weight gain during pregnancy. The atherogenic index of plasma (AIP) and oxidative stress status parameters were determinated in 50 healthy and 172 pregnant women with non-complicated pregnancy. Pregnant women were divided in four groups according to body mass index (BMI) values (BMI quartiles). Oxidative stress parameters were significantly lower in the control group compared with all the pregnant women quartiles. Unexpectedly, differences in oxidative stress parameters between BMI quartiles groups were not significant. The antioxidant defence parameters remained quite similar in the different BMI quartiles. Weight gain and paraoxonase-1 (PON1) activities were independently associated with increased AIP while weight gain and triglyceride concentration were found to be significant predictors of PON1 activities. The results of our current study indicate the association of maternal weight gain during pregnancy and altered lipid profile, elevated oxidative stress and changed antioxidative capacity of PON1. Taken together all these facts indicate possible increased risk of cardiovascular disease (CVD) development in later life if the weight gain during pregnancy is excessive.

Variability of maximum systolic amplitude of ΔZ/Δt curve in pregnancy. Perennial observations

Maximum systolic amplitude is quite an important component of the impedance cardiogram ΔZ/Δt curve. Its values make it possible to calculate many hemodynamic indices. Therefore it is necessary to keep informed about monthly, annual and perennial maximum systolic amplitude trend. We can produce the measuring data of the maximum systolic amplitude for a fifteen-year period (from 1994 to 2009). The impedance cardiograms were obtained with the help of an electric impedance analyzer "RA-5" (1 mA, 70 kHz) with disk ECG electrodes. The data analyzed were taken from the pregnant women with non-complicated pregnancy (n=5709). We have analyzed the average monthly and annual changes of the maximum systolic amplitude ΔZ/Δt curve. It allowed us to reveal the six-year periodicity of the maximum systolic amplitude changes. There were discovered statistically significant peak values difference of the amplitude (p>0.001). The data obtained should be taken into consideration when using impedance cardiography in clinical practice. The article is supplied with tables and diagrams.

Prévenir l’incontinence urinaire postnatale par la rééducation périnéale prénatale ? Rationnel et protocole de l’étude randomisée multicentrique prévention périnéale prénatale (3PN)

Female urinary incontinence (UI) is a frequent affection that generates handicap and expenses. There is a link between UI and pregnancy; onset of UI during pregnancy is a risk factor for permanent UI. Postnatal pelvic floor exercise has shown efficacy to improve postnatal UI. However, it remains uncertain if benefits last more than few months. Publication of our rationale for prenatal pelvic floor exercise is an opportunity to expose our pre-specified hypotheses and help health professionals' awareness. The purpose of PreNatal Pelvic floor Prevention (3PN) is to compare the effects of prenatal pelvic floor exercise versus sole written instructions on UI one year after delivery. It is a multicenter, randomized, single blind study. Main inclusion criteria are first, single and non-complicated pregnancy over 18 years. Women randomized in pelvic floor exercise group will undergo eight sessions with a physiotherapist between six and eight months of pregnancy. Our principal criterion is UI score (International Consultation on Incontinence Questionnaire Short Form [ICIQ-SF]) one year after delivery. We plan to include 280 pregnant women in five centers over a 12-month screening period to show a one-point difference on UI score. ETHIC AND FINANCING: The study was approved by the IRB Comité de protection des personnes Sud-Ouest et Outre-Mer. It was registered by French Health Products Safety Agency (AFSSAPS) and Clinical Trials.gov. It is supported by the French Ministry of Health through the 2007 Hospital Plan for Clinical Research (PHRC). We plan to assess if prenatal pelvic floor exercise reduces postnatal medical consultations or physiotherapy sessions.

Non-complicated pregnancy, anxiety and depression

Non-complicated pregnancy, anxiety and depression

Free IGF-I, IGFBP-1, and the Binary Complex of IGFBP-1 and IGF-I Are Increased during Human Pregnancy

Background/Aims: To investigate changes in free insulin-like growth factor I (IGF-I) and IGF-binding protein 1 (IGFBP-1) complexed IGF-I during human pregnancy. Methods: Overnight fasting serum was obtained in a longitudinal design from 11 women with non-complicated pregnancy at gestation weeks 6–10, 16–20, 24–28 and 35–38 and, for comparison, 5 weeks post-partum. All samples were analyzed for total and free IGF-I and IGF-II, IGFBP-3 and IGFBP-3 proteolysis, total and non-phosphorylated (np-) IGFBP-1, and IGFBP-1 complexed IGF-I. Results: Total IGF-I was increased in late pregnancy (week 35–38) (p < 0.001), whereas free IGF-I was significantly increased by 77% already at week 6–10 (p = 0.004) and by 140% (p = 0.002) at week 34–38, when compared to post-partum levels. At weeks 16–20 and 24–28, levels of free IGF-I were not significantly different from post-partum levels. Significant IGFBP-3 proteolysis was detectable from week 6–10 and throughout pregnancy (p < 0.05). Total and np-IGFBP-1 were significantly increased from 16–20 weeks of pregnancy (both p < 0.05) and IGFBP-1 complexed IGF-I was increased 2-fold from week 16–20 and throughout pregnancy (p < 0.05). However, the saturation of IGFBP-1 remained constant at 27–29% during the study. Conclusion: We found evidence of increased free IGF-I and increased IGF-I in binary complexes during pregnancy, possibly caused by IGFBP-3 proteolysis and decreased ternary complex formation.

Villitis of unknown etiology in placentas of pregnancies with hypertensive disorders and of small-for-gestational-age infants

The objectives of this study are to analyze the frequency and the histopathological features of the villitis of unknown etiology (VUE) in placentas of pregnancies with hypertensive disorders and of small-for-gestational-age infants (SGA). Two hundred and thirteen placentas from pregnancies without clinical or laboratorial evidence of infection were studied. These cases were subdivided according to: a) maternal condition in: non-complicated pregnancy (NCP)- 151 cases, pregnancy-induced hypertension (PIH)- 37 and sustained chronic hypertension (SCH)- 25 and b) newborn weight in: small for gestational age (SGA)- 38 cases and adequate for gestational age (AGA)- 175. Of these placentas, 81 belong to the random sample, which was used to determine the frequency of VUE in the population studied. Eight blocks were taken from placental parenchyma and the histological sections were stained with hematoxylin and eosin. Frequency tables of categorical data were analyzed using the chi- square test and Fisher test; statistical significance was considered for p< 0.05. The frequency of VUE in the placentas was 30.8% in the random sample, 39% in NCP, 29.7% in PIH, 32% in SCH, 34.2% in SGA infants and 37.1% in AGA infants. Placentas of pregnancies with hypertensive disorders were more affected by villitis with parenchymatous component (PIH - 27.0%, SCH - 28.0%). This lesion was also the predominant villitis in the placentas of the SGA infants (31.5%). In contrast, in placentas of NCP and AGA infants, the principal kind of villitis was basal, not associated to a parenchymatous component (16.5% and 14.8% respectively). In the majority of the cases the villitis was mild. In the population studied, the frequency of VUE is high (around 30%). The lesion occurs in a similar frequency in placentas from NCP, PIH, SCH, SGA and AGA infants, but basal villitis not associated to a parenchymatous component affects mainly the placentas of NCP and AGA infants. It is possible that this kind of villitis could be an expression of an antigenic stimulation diverse from villitis with a parenchymatous component.

Clinical Quiz

A 2-month-old girl with severe cyanosis was brought to the emergency department of a local hospital. Because an acute asthma attack was suspected, she was immediately prescribed oxygen therapy, corticosteroids, aerosol with β2-adrenergic agents, and steroids. The infant did not improve after treatment, and she was transferred to the Children's Hospital. On arrival, the infant, the first child of an Italian nonconsanguineous couple and born at term after a noncomplicated pregnancy, was described as irritable. Physical examination showed a pale, cyanotic, and mottled baby. Local emergency room staff noted that the infant was dehydrated, dusky, and cold to the touch. Her temperature was 90°F and her oxygen saturation remained in the low 80s while on 100% oxygen by nasal cannula. The infant had tachycardia (between 150 and 195 beats/min) and tachypnea (60 breaths/min). On auscultation, pulmonary findings were normal. Abdominal examination showed no hepatomegaly, splenomegaly, or tenderness. Neurologic examination did not reveal any deficiency, and the bregmatic fontanel was normal. The infant's weight was 4,720 g (10–25th percentile), length was 54 cm (10–25th percentile), and head circumference 39 cm (10–25th percentile). The growth charts show no failure to thrive. Laboratory tests showed increased leukocytes, normal platelet count, and normal concentrations of hemoglobin and hematocrit. An important finding was significant methemoglobinemia (30.4%) and profound hypoxia (20.4 mm Hg). Radiography and electrocardiography findings were normal. According to her parents, the infant's skin color had become “grey” and she had been particularly irritable for a couple of weeks. For the first 2 weeks of life, the child was exclusively breast-fed. She was then artificially fed because breast milk was not available. The parents reported that at 4 weeks of age, the baby experienced constipation. A pediatrician whom they consulted suggested a conventional, adapted milk formula reconstituted with courgette soup (120 mL for six meals). What is the diagnosis? 1. Eisenmenger syndrome 2. Blue baby syndrome 3. Ebstein anomaly 4. Deficit of very long-chain acyl dehydrogenase 5. Sepsis 6. Carbon monoxide intoxication Answer: Blue baby syndrome. When a cardiorespiratory problem had been excluded, intoxication was suspected. The parents reported that the child was fed formula reconstituted with courgette soup to resolve constipation. In fact, the available data supported the final diagnosis of infant methemoglobinemia caused by the ingestion of concentrated vegetable soup (blue baby syndrome). Treatment with 0.1 mL/kg 1% methylene blue and 1 g vitamin C soon resolved the symptoms. Comment: Accumulation of methemoglobin in red cells can occur for three reasons: 1) a dominantly inherited abnormality in hemoglobin that prevents the reduction of methemoglobin to hemoglobin; 2) a recessively inherited deficiency in the enzyme methemoglobin reductase; or 3) exposure to hemoglobin-oxidizing chemicals or drugs, such as nitrates or nitrites contained in water and in some vegetables (such as carrots, spinach, courgette, cauliflower, red beets), Xylocaine, or benzene derivatives. Blue baby syndrome, known as infant methemoglobinemia, is not an infrequent condition. Infants younger than 6 months of age are particularly susceptible to methemoglobinemia because they have smaller amounts of a key enzyme, NADH-cytochrome b5 reductase, which converts methemoglobin back to hemoglobin (2). For more than 40 years, nitrates in drinking water have been believed to be a primary cause of infantile methemoglobinemia. Nonetheless (3–5), some cases of infantile methemoglobinemia have involved infants who became ill after being fed formula that was reconstituted with vegetable soup and nitrate-free water. Our case suggests not feeding infants with increased amounts of vegetable foods, such as carrots, courgette, spinach, red beets, and cauliflower, to resolve constipation, because doing so may be a risk factor, particularly in the first months of life, for severe methemoglobinemia (1,6).

Spontaneous coronary artery dissection in a pregnant woman

BACKGROUND: Spontaneous coronary dissection is a rare condition occurring more often in women, with a higher frequency during the peripartum period. No specific etiology has been defined to describe this uncommon, yet often fatal phenomenon. CASE: A young woman presented at 36 weeks of a noncomplicated pregnancy with recent onset of diaphoresis, dyspnea, and tingling substernal chest discomfort. Upon evaluation, she developed cardiovascular collapse and ventricular fibrillation requiring aggressive resuscitative measures, eventually leading to extracorporeal membrane oxygenation. Right coronary artery dissection was ultimately diagnosed and treated with intracoronary angioplasty and stent placement. CONCLUSION: Spontaneous coronary dissection must be considered when evaluating a patient with a similar clinical presentation, given its overall mortality of more than 50% at presentation, particularly in the peripartum period.

Spontaneous Coronary Artery Dissection in a Pregnant Woman

In Brief BACKGROUND Spontaneous coronary dissection is a rare condition occurring more often in women, with a higher frequency during the peripartum period. No specific etiology has been defined to describe this uncommon, yet often fatal phenomenon. CASE A young woman presented at 36 weeks of a noncomplicated pregnancy with recent onset of diaphoresis, dyspnea, and tingling substernal chest discomfort. Upon evaluation, she developed cardiovascular collapse and ventricular fibrillation requiring aggressive resuscitative measures, eventually leading to extracorporeal membrane oxygenation. Right coronary artery dissection was ultimately diagnosed and treated with intracoronary angioplasty and stent placement. CONCLUSION Spontaneous coronary dissection must be considered when evaluating a patient with a similar clinical presentation, given its overall mortality of more than 50% at presentation, particularly in the peripartum period. We describe a case of spontaneous coronary artery dissection in a peripartum woman requiring extracorporeal membrane oxygenation and intracoronary stent placement.

Circulating bufodienolide and cardenolide sodium pump inhibitors in preeclampsia.

To determine plasma levels of the endogenous bufodienolide Na+/K+ ATPase inhibitor, marinobufagenin-like factor (MBG), in normotensive pregnancy and in preeclampsia, to compare changes of MBG with that of ouabain-like compound (OLC), and to characterize the purified MBG immunoreactive factor from preeclamptic plasma. Consecutive sample study. The levels of MBG and OLC compounds were measured in extracted plasma by solid phase fluoroimmunoassays. MBG and ouabain immunoreactive materials were partially purified from preeclamptic plasma via reverse-phase high-performance liquid chromatography (HPLC) and studied for their ability to cross react with MBG and ouabain antibodies, and to inhibit the Na+/K+ ATPase from human mesenteric arteries. Vasoconstrictor effect of authentic MBG was studied in isolated rings of human umbilical arteries. In 11 nonpregnant control individuals, plasma concentrations of MBG and OLC were 0.190+/-0.04 nmol/l and 0.297+/-0.037 nmol/l, respectively. In the third trimester of noncomplicated pregnancy (n = 6), plasma MBG increased (0.625+/-0.067 nmol/l, P<0.05), and OLC did not (0.32+/-0.07 nmol/l). In 15 patients with preeclampsia, plasma levels of both MBG and OLC increased dramatically (2.63+/-0.10 nmol/l and 0.697+/-0.16 nmol/l, respectively, P<0.01 versus both control groups). When fractionated by reverse phase HPLC, OLC was eluted by 18% acetonitrile, and MBG by 48% acetonitrile. Serially diluted samples of MBG and OLC immunoreactive materials from HPLC fractions reacted with MBG and ouabain antibody in solid phase immunoassay in a concentration dependent fashion. Authentic MBG caused contractile responses of isolated rings of human mesenteric arteries in a concentration-dependent manner. Similarly to the authentic MBG, HPLC purified MBG immunoreactive material from preeclamptic plasma inhibited Na+/K+ ATPase purified from human mesenteric artery. Our observations demonstrate the coexistence of two endogenous cardiotonic steroids in preeclamptic plasma, a more polar OLC and a less polar MBG-like compound. Substantial increases in plasma OLC and MBG immunoreactivity in preeclampsia, along with the vasoconstrictor properties of authentic MBG and Na+,K+ ATPase inhibitory activity of human MBG immunoreactive factor, suggest, that in preeclampsia, plasma concentrations of MBG are enough to substantially inhibit the sodium pump in cardiovascular tissues, and are in accordance with the views attributing endogenous digitalis-like factors a pathogenic role in the preeclamptic hypertension.

Mast-cell-basophil system in noncomplicated pregnancy and in the late toxaemia of pregnancy

Mast-cell-basophil system in noncomplicated pregnancy and in the late toxaemia of pregnancy